NGN-Style Questions—What Should We Do Now?

By Susan Sportsman PhD, RN, ANEF, FAAN

 The National Council of State Boards of Nursing (NCSBN) recently posted on their website five types of questions that they will include as part of the Next Generation NCLEX (NGN) test revision. While the NCSBN intends to continue to use the multiple-choice test format which currently makes up a significant portion of the NCLEX exam, other types of test items will also be included. Box A below highlights the structure of these test items.  For more information, go to Betts, (2019) and/or “The Right Decisions Come from the Right Questions”.

 Box A:  New NGN Test Question Protocol

Extended Multiple Response (MR) This approach allows for multiple correct answers, similar to current NCLEX Multiple Response items, but with more potential answers. No direction is given regarding the correct number of answers for each item.
Hot-spot/ Highlighting (HL) Respondents are able to highlight and then click on as many text phrases in the scenario as necessary to answer the question. Information may also be presented in a table format, such as a laboratory report or a schedule of medications.
Drop-Down (DD)

Also Known as CLOZE

A menu is provided which allows respondents to choose a piece of important information in order to answer the questions. The choices may be embedded in either text or tables. This is similar to the current CLOZE format, with the addition that there may be some incorrect options that should not be selected.
Drag and Drop (DND) Potential answers can be dragged to specific target locations, including target areas within the sentences, in order to answer the question. Drag and Drop allows test-takers to view all answer choices in a single viewing. This type of question allows prioritization.
Matrix/Grid The Matrix/Grid format includes two types of items, the multiple-choices and multiple responses. The Multiple-choice form options are presented in a table format and each row has one correct answer. The Multiple- Response form allows each column in the table to be an independent answer. For example, a number of symptoms from a case study can be presented and respondents are asked to identify sets of symptoms that indicate a particular disease process, even when the symptoms are not necessarily independent across disease processes. This type of test item gives the opportunity to test multiple aspects of a clinical situation in one question.

(Adapted from Betts, et al, 2019)

The new test items discussed above feature clinical scenarios that highlight the interaction between the nurse and the client, the needs of the client, and the expected outcomes. The NCSBN indicates that 65% of the nursing errors involve clinical judgment and 50% of those errors involve a novice nurse. These statistics informed the need to revise the NCLEX testing process to more effectively assess new graduates’ clinical judgment prior to issuing a license to practice nursing; thus, the initiation of the NGN research process.

The NGN researchers utilized the Cognitive Continuum Theory to guide their work.  The Cognitive Continuum theory states that well-structured problems with a greater numbers of cues to be considered in making a decision increase the likelihood that decision-makers will rely on analytical decision-making.  On the other hand, decision-makers are more likely to rely on intuitive methods when the problem situation has fewer cues and greater levels of ambiguity. The Cognitive Continuum Theory underscores the idea that developing competence in clinical judgment requires that testing MUST be based upon the use of clinical scenarios with limited ambiguity but sufficient structure for a novice nurse (Betts, et al, 2019), a theoretical approach that all test-writers should use.

Preparing for the NGN

Although the complete transformation of the NCLEX examinations will likely not happen until 2023, nurse faculty want to know what can be done NOW to ensure that their students are prepared for the NGN NCLEX when it is rolled out. Complicating the picture is that testing platforms in many institutions do not allow faculty to develop test items that mirror the Extended Multiple Response, Hot Spot/Highlighting, Drop-Down, Drag and Drop, or Matrix/Grid. Publishers of testing materials are working to adapt to these changes, but in the meantime, what can nursing faculty do to prepare students to make effective clinical judgments (and be successful on the NCLEX exam)?

Test-Writing Recommendations

Here are some test-writing recommendations that I believe will be helpful as we move down the path toward full implementation of the NGN.

First, frame all your test questions in a clinical context, consistent with the instructions given to the Subject Matter Experts (SMEs) developing NGN questions. They are being asked to write scenarios that involve naturally occurring situations that entry-level nurses commonly encounter in practice. This focus should also apply whether you are writing your own test questions or individualizing items from a test-bank. This approach is consistent with Benner’s (2009) recommendation that nursing faculty must shift from a sharp separation of clinical and classroom teaching to an integration of classroom and clinical teaching. This applies to testing processes as well!

Developing the Scenario

  • Integrate elements of the Clinical Judgement Measurement Model established by the NGN research into each scenario. The test-taker will have to recognize or use these elements in the scenario in order to correctly answer the test item. When writing the scenario, the test writer should ask the following questions:
    1. Are there environmental, medical record, or patient observation cues described within the scenario?
    2. Do the patient observation cues reflect normal and abnormal cues, signs and symptoms, and/or a historical perspective of the cues?
    3. Are there environmental factors, such as time pressure, that will impact the decision-making of the test-taker?

 Reviewing the Scenario

  • Once the test item scenario is written (or revised), follow the recommendation given to the SMEs who were reviewing the newly written NGN questions, by asking yourself:
    1. Is the scenario something that an entry-level nurse would see in actual clinical practice?
    2. Is it appropriate for an entry-level nurse in the late beginning stage of developing clinical judgment competence?
  • The scenario should provide the test-taker with sufficient information to answer the question posed. Review of the scenario to insure completeness includes answering the question: Are the cues sufficient to:
    1. Analyze the cues in order to identify client need(s)?
    2. Prioritize client need based upon risk, likelihood of occurrence, and/or influencing environmental factors?
    3. Generate solutions, including things to address and things to avoid?
    4. Identify the specific action(s) that should be taken (or not taken)?
    5. Plan an evaluation of the actions taken?
  • Are there reasonable distractors that require nursing knowledge to eliminate?

(Adapted from Betts, et al, 2019)

Plans for Employing the NGN and its Influence on Nursing Program Testing

The NGN research team intends to present the stem of the test item as a scenario and, using some of the new question formats, ask several pertinent questions about each scenario. The NGN technological testing platform can add these additional questions to the computer screen without having to re-introduce the scenario. This approach reduces the time required to process the questions, because the narrative component of the screen doesn’t change as new questions are added. Most of us do not have a testing platform with that capability, so our scenarios will likely need to be repeated (at least in part) in the testing platform as students move through the scenario we have developed. This, of course, breaks a test-writing rule that we all have learned (and I have taught!) that each question must be independent of others to insure that test-takers don’t spend too much time finding the scenario and re-reading it. Until we have access to NGN-like technology, we must balance the need for reading convenience against the need to analyze multiple problems within a single test item.

 What can Nurse Faculty Do Now?

Despite the limitation resulting from disparate platform technology, the work reported by Betts and his colleagues (2019) gives us direction for developing and revising our current test items, even if we can’t (at least at this point) mimic the exact presentation of the NGN question format.  We CAN, however, focus on testing clinical judgment in our tests, to the extent possible, using the above steps to develop the scenarios we use.

We can also provide learning activities in class, lab/simulation, and clinical that provide students opportunities to identify and analyze cues, develop and prioritize hypotheses, generate solutions, take action, and evaluate outcomes. The steps discussed above can also inform a variety of active learning teaching strategies that engage the students in their learning. In a future article we will explore how the NGN Clinical Judgment Measurement Model can help us develop clinical judgment through all teaching/learning interventions. In the meantime, let’s all focus on using testing scenarios that improve clinical judgment.

Best of luck as we move down this path together.


Benner, P. Sutphen, M., Leonard, V., Day, Lea, S. (2009) Educating Nurses:  A Call for Radical Transformation.  Jossey-Bass. p. 86

Betts, J., Muntean, W., Kim Doyoung, K., Jorion, M, Dickison, P. (2019) Building a method for writing clinical judgment Items for entry level nursing Exams.  Journal of Applied Testing Technology 20(S2) 21-36.

NCSBN (2019) Approved NGN Item Types. ( Accessed, January, 2020.

NCSBN (2019) The Right Decisions Come From the Right Questions. ( Accessed, January, 2020.

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