The “Application or Higher” Dilemma in the Era of Next Generation NCLEX

Writing test items for a faculty-made test is perhaps one of the most difficult tasks that a faculty member faces. In Critical Thinking in Test Item Writing, Morrison, Nibert, and Flick (2006) emphasize the importance of crafting a test item that requires test-takers to at least apply content in order to correctly answer the question. This recommendation reflects the National Council of State Board of Nursing’s policy that all NCLEX test items require cognition at the application level or higher. Yet, we all know how difficult it is to develop test items that correspond to the upper levels of Bloom’s Taxonomy of Cognitive Behavior. 

Over the years, as I have led faculty development workshops on test writing, I have participated in many discussions about how to meet the standard of “application or higher” cognitive test items. Typically, the focus of these discussions goes like this: 

Students must learn the content before they can apply or analyze it.  So, we must test their knowledge level, and then we can test their ability to apply, analyze, evaluate, or create.

At the end of each discussion, faculty often share testing strategies they use to gradually introduce higher order thinking into the testing process. Many times the solution is to set the percentage of lower-level test questions for each test within the course or curriculum level, gradually increasing the percentage of test items that represent application or higher cognitive level over the students’ course of study.

I appreciate that these testing strategies move students toward application intentionally, instead of writing test items without considering the cognitive level appropriate for best outcomes. I also have certainly used these strategies in tests that I have constructed over the years.  

However, we are preparing for the introduction of the Next Generation NCLEX (NGN) and the central component of this new approach is to accurately test students’ ability to effectively use clinical judgment. As part of the development of the NGN, the NCSBN project team developed a definition of clinical judgment below that bears repeating:

This diagram demonstrates how important critical thinking and problem solving are to effective clinical judgment. I would submit that we must intentionally increase the opportunities for students to practice clinical judgment. Of course, this can be accomplished through learning strategies in class, lab, or clinical experiences that require students to actually apply the content they are learning.  It also includes emphasizing upper level cognitive levels in faculty-made tests. I believe effective use of test items that requires application can be introduced even in the early nursing courses.  In the NCLEX Test Design, sample test questions demonstrate how test questions requiring clinical judgment can be developed for even beginning level content. Here is just such an example:

As a strategy to prepare for the NGN, I challenge all of us to increase the number of questions written at higher cognition levels on each of our tests. Over the course of time we might be able to have the majority of our test items, even in introductory courses, emphasize clinical judgment through application, analysis, evaluation or creation. Ultimately we might have 100% of our tests-items (at least in some courses) that represent the higher cognitive levels.

What do you think? Have you been successful in this endeavor? I would love to hear how you are progressing!