by Susan Sportsman, PhD, RN, ANEF, FAAN
Last week I joined four hundred-plus nurse educators from the US and Canada to participate in the 2019 NCSBN NCLEX Conference in Phoenix, Arizona. From my perspective, here are the highlights of this event.
The speakers from the morning session of the conference focused on information about the structure and processes in the current NCLEX. The afternoon session discussed the progress of the development and implementation of the Next Generation NCLEX (NGN) project. Because everyone (including me) was particularly interested in the staff’s discussion of NGN, I will focus on the highlights from this section of the meeting.
Here are the items that seemed particularly important to me.
- The Fall 2017 NGN News, the first NCSBN communication about the NGN project, promised that “if the evidence [resulting from project implementation] doesn’t support the rigor and quality of the NCLEX at any point, the project and the timeline will be reexamined.” Over time, those involved in the project recognized that a decision to “Stop or Go” would have to be made. At the most recent meeting, NCSBN staff indicated that they had reached the point where there was sufficient support for the project to “Go” (continue with the project). What remains uncertain is when the new NGN will be fully implemented—no sooner than 2023, but perhaps 2024 or 2025.
- The NCSBN Clinical Judgement Model illustrates four levels of behaviors that occur during the clinical judgment model. Although the Nursing Process, which is central to our practice, is not highlighted in the model, the speakers made the point that level 2, 3, and 4 of the CJM is congruent with the intent of the Nursing Process (Assessment, Diagnosis, Plan, Implement, and Evaluation). Take a look at the model and see if you agree.
- Everyone I talk to about the implementation of the NGN wants to know the type of test items that will be used for the NGN. The speakers described several types of questions that may be included in the NGN testing process. These include:
- Multiple Choice (with which we are all familiar)
- Select All That Apply (SATA) – Currently, the responses to the SATA are graded as either right or wrong. The NCSBN psychometricians are currently working to develop a scoring mechanism that will allow partial credit when the students choose some of the correct answers, but not all of them.
- Extended Multiple Response (EMR)—A test item type similar to the SATA. An example of such a test item is one which gives a presentation of various assessment items, requiring the test-taker to determine whether the client’s condition is improving, worsening, or is unrelated. Another example might be providing data from a patient’s record and asking the test-taker to highlight what data is important in the context of the situation.
- CLOZE questions-These questions are structured as a “fill-in-the blank” question, with drop-down options from which to choose.
Again, these types of test items and others are still being developed, tested, and reviewed, and scoring approaches are being analyzed to determine whether clinical judgment and decision-making in nursing can be reliably assessed through the use of innovative item types. We do not know exactly what the final test item will look like. Similarly, we do not know what software will be required.
Certainly, it is stressful for faculty to wonder if we will know how to develop appropriate test items or whether our programs will have the appropriate testing equipment to provide students with the appropriate test questions. However, since the NGN developers are not finished with their work, faculty cannot deal with these concerns at this time. So, what can we do to prepare our students and ourselves for these changes?
To answer this question, let’s stop a moment and think, “What is the underlying goal for the NGN and how can we prepare students to achieve that goal?” Since the purpose of the NGN project is to determine whether clinical judgment and decision-making in nursing care can be reliably assessed through the use of innovative test items, I would recommend that we focus on ensuring that students can make effective clinical judgments as they begin their practice. We must build upon our current teaching and evaluation methods, by intentionally integrating the clinical environment (real or simulated) into all of our teaching/evaluation activities.
For example, let’s take the Extended Multiple Response (EMR) Question discussed earlier. In our example, the test item required the test-taker to analyze the results of a focused assessment and determine what each result means in terms of the client’s overall condition. Certainly, this is a competency necessary for the novice nurse. This type of item requires more complex analysis than many of the test items we currently use. So what are some specific strategies that faculty could intentionally introduce to students to give them practice to develop this competency? What other evaluation strategies might you use to evaluate their level of competence—whether for a grade or simply oral or written feedback? I have identified a few strategies in Table A below; however, there are many others that I expect you could suggest.
Table A: Teaching Activities and Evaluation Strategies to Prepare for an EMR Question
| Teaching Activities | Evaluation Strategies |
| Present the results of a focused assessment relevant to the topic being discussed in class. Ask students individually or as small groups to evaluate the results relative to the client’s condition. | Use the SATA test item format to query students about this information. |
| Integrate a discussion of the meaning of the assessment done in a simulation experience. | Immediately after closure of a simulation experience, ask students to write down which assessment findings represented improvement or worsening of the client’s condition. Provide feedback to students individually or as part of the debriefing exercise. |
There are many, many ways to integrate clinical judgment into teaching activities and current test items. The key is to intentionally focus on clinical judgment in both teaching activities and evaluation strategies you implement throughout the course.
Spending the day at the 2019 NCLEX Conference crystallized for me an important element in guiding the preparation of students for practice as a novice nurse:
Underlying Clinical Knowledge + Ability to Use Clinical Judgment = Effective Nursing Practice
Underlying Clinical Knowledge – Ability to Use Clinical Judgment = Ineffective Nursing Practice
With this principle in mind, we must intentionally provide opportunities for students to be exposed to critical clinical knowledge. However, we must also intentionally provide them with many opportunities to integrate this knowledge into clinical situations in class, lab, simulation, and clinical experiences. And, we should do this each time we interact with students, regardless of the testing methodology we use.
The NGN project has focused our attention on Clinical Judgment. The NCSBN has not yet completed this work. However, throughout this developmental process, they have demonstrated an impressive level of transparency, sharing with all of us their actions and findings throughout the steps of the process. As one of representative of the NCSBN who served as a moderator for one of the conference sessions said, “Providing transparency throughout the process results in a number of unanswered questions at any given time.”
The NGN will not be implemented until 2023 at the earliest. Despite the fact that “not knowing” makes all of us uncomfortable, my recommendation is that we focus on intentionally providing students with the opportunity to apply their knowledge into a real or simulated clinical scenario every time they come to class, lab or clinical experience, have an out-of-class assignment, or take a test. If we do that, our students will be ready for the NGN (whatever form it takes) and for practice.
We will continue this discussion of preparing students to make effective clinical decisions as a novice nurse. Stay tuned!