Mentai status is defined as a person's emotional and cognitive function (Jarvis, 1992). It is evaluated by components such as appearance and behavior; memory and attention span; thought processes and perceptions; and tests of higher cognitive function. One characteristic of higher cognitive function is the ability to think abstractly. Standard tests used to assess abstract thinking include asking the client to tell how two similar things such as a cat and mouse are alike and stating the meaning of a proverb. These tests are used to discriminate between the average client and those with organic brain disease. Results of these tests are related to general intelligence, educational level, and cultural influences.
The impetus for this pilot study came from the author's experience in teaching health assessment to sophomore level students in a baccalaureate nursing program. Students were often unable to state a proverb when asked what types of proverbs they had heard used in casual conversation. Some students stated they didn't even know what a proverb was. After describing an abstract and concrete interpretation of a selected proverb students were asked to validate a mental status assessment on a peer and document their findings. Student documentation of the mental status assessment reflected that some students did not understand how to identify if an individual demonstrated abstract reasoning skills.
Abstract reasoning is the ability to think beyond what is concrete or real. Piaget (1975) identified the process of formal operations including abstract reasoning as an adolescent developmental stage usually occurring between the ages of 12-15. The reliability and validity of using the interpretation of proverbs as a measure of abstract thinking has been challenged by several authors. They are seldom used in a standardized manner with any type of scoring criteria. Andreasen (1977) identified that proverb interpretation possessed relatively strong validity but poor reliability in determining clients with organic brain disease. Reich (1981) discovered little success in correlation between interrater reliability when the interpretation of an individual proverb was tested. However, the correlation of interrater reliability was statistically significant when the sums of the interpretation of four proverbs were tested. Keller and Manschreck (1981) noted the use of similarities and proverb interpretation was greatly influenced by intelligence level and had questionable validity. Although little systematic research has been performed regarding proverb interpretation as a measurement of abstract thinking it is often listed in current assessment texts. A recent review of seven current health assessment texts (Bates, 1991; Fuller & Schaller-Ayers, 1990; Bowers & Thompson, 1992; Jarvis, 1992; Malasanos, Barkauskas, & Stoltenberg-Allen, 1990; Morton, 1993; and Seidel, Ball, Dains, & Benedict, 1991) demonstrated that 85% describe proverb interpretation as a measurement of abstract thinking.
All sophomore level students enrolled in a health assessment course were given a list of eight proverbs. "Don't count your chickens before they hatch." " A bird in the hand is worth more than two in the bush.* "The squeaky wheel gets the grease." "A rolling stone gathers no moss." "A stitch in time saves nine." "The proof of the pudding is in the eating." "An ounce of prevention is worth a pound of cure." "A penny saved is a penny earned."
A definition of abstract thinking was given to the class. The proverb "don't cry over spilled milk," was used as an example describing concrete and abstract interpretations. Students were then given 15 minutes to write brief abstract interpretations for the list of eight proverbs. They were told if they had no idea what an individual proverb meant to leave the response area for that proverb blank. Additionally students were instructed to write their current age on the paper and not to provide any other type of identification.
All 46 students present in the class completed the assignment. The average age of the students in the class was 20 with a range from age 19-42. There were four students in the class over age 30. These students were all practicing nurses returning to school to obtain a baccalaureate degree. Only 20 students (44%) could give abstract interpretations for all eight proverbs. Interestingly, the four students over age 30 were included in this group. At least 50% of the students could not offer an interpretation of one or more proverbs. Six students (13%) described concrete interpretations for one or more proverbs. For example, "if a stone keeps moving no moss will appear on it" was the interpretation given for "a rolling stone gathers no moss." Some students (22%) provided abstract interpretations that didn't match the proverb. Interpretations for "the squeaky wheel get the grease" included; "put effort behind your work;" "if it's broken, fix it;" "if you talk about people and tell on them you'll get in trouble;" and "if a person talks too much everyone will shut him up."
This pilot study has several limitations. The small sample size does not permit any typeofgeneralizability toa larger student J population. One must be careful not to assume a blank response to one of the proverbs indicates a failure to understand the proverb. Students may have chosen *| not to fully participate in an assignment which had no influence on the course grade. Although the four older students could successfully give an interpretation to each of the proverbs this does not necessarily mean that older adults are better able to demonstrate abstract thinking skills when compared to a group of individuals in late adolescence. Asking students to provide interpretations of proverbs may not be an appropriate indicator of their ability to abstract reason. Students should have been provided some other sort of abstract thinking measurement such as describing similarities between a list of two things such as a theater and a church or an apple and an orange.
This study also indicates that further validation and reliability studies on proverb interpretation is necessary. Asking an individual to provide an abstract interpretation of a proverb when they have never been exposed to proverb use in casual conversation may be an inappropriate test of abstract reasoning skills. Additionally a comparison study of an individual's abstract reasoning skill using both the proverb interpretation and similarity comparison between two like objects is warranted. If a goal of the mental status assessment is to identify an individual with organic brain disease through measurement of abstract reasoning skills, can this be done with similarity comparison alone?
However, even these preliminary results have implications for nurse educators. If we continue to teach students to use proverb interpretation as a test in the mental status assessment we need to inform students of the possible limitations. It would be wise at this time to advise students to use both interpretation of proverbs and asking the client to describe similarities between two like objects when administering tests of abstract thinking. Educators must be sure that students can adequately interpret proverbs before they perform client mental status assessments. These results indicate that just defining abstract thinking and providing an example of concrete and abstract interpretations of a proverb does not ensure student understanding.
- Andreasen, N. (1977). Reliability of proverbs: Proverb interpretation to assess mental statua. Comprehensive Psychiatry, 18(5), 465473.
- Bates, B. (1991). A Guide to Physical Examination and History Taking (5th ed.). Philadelphia: J.B. Lippincott.
- Bowers, A. & Thompson, J. (1992). Clinical Manual of Health Assessment. (4th ed.). St. Louis: Mosby- Yearbook, Inc.
- Fuller, J. & Schaller-Ayers, J. (1990). Health Assessment. Philadelphia: J.B. Lippincott.
- Jarvis, C. (1992). Physical Examination and Health Assessment. Philadelphia: W.B. Saunders.
- Keller, M.B. & Manschreck, T.C. (1981). The bedside mental status examination - Reliability and validity. Comprehensive Psychiatry, 22(5), 500-511.
- Malasanos, L., Barkauskas, V., & StoltenbergAllen, K (1990). Health Assessment (4th ed.). St. Louis: CV. Mosby.
- Morton, P. (1993). Health Assessment in Nursing (2nd ed.). Springhouse, PA: Springhouse Corporation.
- Piaget, J. (1975). The Construction of Reality in the Child. New York: Ballantine.
- Reich, J.H. (1981). Proverbs and the modern mental status exam. Comprehensive Psychiatry, 22(5), 528-531.
- Seidel, H., Ball, J., Dains, J., & Benedict G. (1991). Mosby's Guide to Physical Examination (2nd. ed.). St. Louis: Mosby- Yearbook, Inc.