1. Mayo, Ann M. DNSc, RN, CNS, FAAN

Article Content

Reliability and validity measurement issues are nothing new to clinical nurse specialists (CNSs). Over the years, this journal has published a plethora of articles addressing measurement, and as students, CNSs were educated in programs about the importance of reliability and validity as applied to instrument selection, usage, and interpretation of scores. As a result, healthcare organizations know that their CNSs are the go-to professionals when a process or outcome needs to be measured. A recent announcement from the Montreal Cognitive Assessment (MoCA) Clinic and Institute demonstrated the importance of liability as a third element to be considered when selecting and using instruments for measurement and evaluation. Liability is nothing to be taken lightly, particularly in the field of geriatrics, where measures of cognition are used to inform life-changing decisions for older adults that can trigger complaints by patients and families unhappy with the results.


Cognitive problems among older adults are widespread. Cognitive screening is frequently performed by healthcare providers across all practice settings, but not all of them are qualified to administer these seemingly simple instruments. An up-to-date, reliable cognitive screen that produces valid results is imperative for determining if an older adult should undergo more extensive cognitive testing to determine a diagnosis, appropriate treatment, decision-making capacity, or continued ability to drive. For decades, healthcare professionals across all settings have utilized the Mini-Mental Status Examination (MMSE) as an important screening instrument.1 However, an alternative to the MMSE was developed in the 1990s when a cost became associated with administering the MMSE. The MoCA, developed in 1996, was subsequently adopted by many healthcare organizations because there were no associated costs and the psychometric testing properties (validity and reliability) of the MoCA were determined to be similar to those of the MMSE. In addition, the MoCA was determined to be more sensitive to cognitive changes among older adults with mild cognitive impairment, not just those with dementia.2


As of September 1, 2019, all new users of the MoCA will be required to complete training and testing to obtain certification to administer the MoCA ( Current users will have 1 year to complete their training (by September 1, 2020). Standardized training and validation of competency testing will take 1 hour to complete. Cost for this training, testing (3 trials allowed over a 2-month period), and a 2-year certification will be $125.00. Information about institutional licensing and group accounts is available (


The requirement for training enacted by the MoCA Clinic and Institute is the result of legal threats made by patients and families who have disagreed with diagnoses that have been based upon MoCA results. Specific complaints by patients and families included the following: their provider not being trained to administer the instrument and their provider not being able to interpret the results. As the Institute warns, "If you wish to continue using the MoCA Test without being officially trained and certified, you will be at increased risk for administration, scoring and interpretation errors which could lead to misdiagnosis and liability" ( Rather than not using the MoCA to avoid being vulnerable, embracing the certification process will strengthen nursing practice. Understanding a patient's cognitive status allows us to more effectively communicate with older adult patients. In addition, when performed on a regular basis (eg, annually), testing allows the patient and family to have a more accurate perception of the patient's cognitive issues. Ultimately, plans of care will more accurately reflect a true cognitive assessment, decreasing overall healthcare liability such as when nurses are consenting patients, preparing patients for discharge, and coordinating safe medication management.


Clinical nurse specialists need to provide leadership in ensuring that nurses are qualified to reliably measure important clinical indicators like cognitive status. Data entered into medical records must be valid data. As one recommendation, annual skills days should incorporate time for instrument training, testing and results interpretation, followed by appropriate recognition for nurses who complete this important process. Savvy patients and families are paying attention to nursing practice and the outcomes of our assessments. To maintain our privileged position as the experts of measurement and the go-to professionals for measurement, CNSs need to provide leadership for promoting competency and diminishing liability for ourselves, our nurses, and our organizations.




1. Brugnolo A, Nobili F, Barbieri MP, et al. The factorial structure of the mini mental state examination (MMSE) in Alzheimer's disease. Arch Gerontol Geriatr. 2009;49(1):180-185. [Context Link]


2. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-699. [Context Link]