By Susan Sportsman, PhD, RN, ANEF, FAAN
On September 14, 2020, I participated in the first-ever virtual 2020 NCLEX Conference offered by the National Council of State Boards of Nursing (NCSBN). There were many interesting presentations, but I believe that you will agree that the discussion about Next Generation NCLEX (NGN) was most important for nursing educators. So here is an overview of the discussion about NGN.
The research regarding the effectiveness of the NGN’s approach to testing students’ competence in clinical judgement is ongoing. Through the Special Research Section in the current NCLEX examination, data has been collected on over 7 million test-taker responses to over 1,300 NGN test items. Although test-takers are not required to answer the questions on the Special Research Section of the NCLEX-RN, nearly 90% (over 500,000) of the NCLEX examinees have responded to at least some of the items and over 300,000 completed the entire section. This is good news, because the robust data collection has supported the assessment of the Clinical Judgement Measurement Model (NCJMM) and various related testing approaches.
The NCSBN representatives stated that the NCLEX NGN will not be rolled out before April 2023. This gives nurse educators 2½ years to prepare for this new approach to the NCLEX.
The Special Research Section was removed from the NCLEX-RN during the Pandemic in order to reduce the amount of time test-takers spent in the testing center. In October 2020, the NCSBN plans to reintroduce the Special Research Section with the NCLEX-RN. At that time, the section will also be included in the NCLEX-PN. In 2023, both NCLEX examinations will use the NGN approach.
Use of Case Studies
The Next Generation NCLEX will use Unfolding Case Studies, at least in part, as a means of delivering sets of test questions to the test-taker. Each case is presented to the test-taker on the computer screen; the patient’s clinical information related to the patient and his/her condition will be presented on the left side of the screen. The right side of the screen will present the question to which the test-taker will respond. As the case moves forward, additional information (nurses notes, lab values, etc.) about the case will be available on the left side of the screen and the test-taker will be directed to the added information. The six question for each case study, known as a test set, will be presented as the case unfolds.
Questions presented in the unfolding case studies will be based upon the NCSBN Clinical Judgment Model Level 3 (Recognizing Cues, Analyzing Cues, Prioritize Hypothesis, Generated Solutions, Take Action and Evaluation).
For example, a question may ask the test-taker to select important cues that provide information that directs the care of the patient presented in the case study. The second question will require analysis of the cues; the third, prioritization of hypotheses, and so on, until the final question requires test-takers to use the data given on the left side of the screen.
Level 4 of the NCSBN NCLEX Clinical Judgment Measurement Model is also present in the unfolding case study. Level 4 represents both environmental factors and individual factors of the caregiver. For example, environmental factors might include cultural issues in the case study or time pressure experienced by the nurse, while individual factors might include knowledge, skills, or experiences of the nurse relevant to the care of the patient.
Types of Questions and Scoring Rules
The NCSBN staff has developed the scoring rules that they will use to grade NGN-style questions. The three scoring rules that will be applied include:
O/1 Scoring Rule
This rule, the classic approach to scoring exam questions, indicates that the test-taker will earn 1 point for a correct response, but will not earn a point for incorrect responses. If there is more than one correct response in the question, the total number of correct responses represent the points received. The type of questions that use the 0/1 Scoring Rule include:
- Multiple Choice (the traditional type of questions)
- Drop Down Cloze (similar to fill-in-the blank questions)
- Drop Down Tables
- Select a Specific Multiple Response
- Matrix Multiple Choice
+/- Scoring Rule
This rule allows test-takers to earn points for each correct choice AND lose a point if they choose incorrectly. This rule provides higher scores when they identify and select more of the pertinent information provided in the question. The type of questions that use the +/- Scoring Rule include:
- Select All Multiple Responses
- Matrix Multiple Responses
- Grouped Multiple Response
Rationale Scoring Rule
This type of question requires a full understanding of paired information. For example, a nurse must do X because of Y. In this situation, both X and Y must be correct to earn a point. The type of question that supports such grading includes the Drop-Down Rationale.
I realize that some of these types of questions may be unfamiliar to you. I would direct you to view the NGN News Fall 2019: Approved NGN Types to learn more. This publication illustrates Multiple Choice, Drop Down Cloze, Drop Down Table, Highlighting, and Matrix Multiple Responses. Other question types are illustrated in Next Generation NCLEX NEWS, Layer 4 of the NCSBN Clinical Judgment Measurement Model (NCJMM). There are some additional new examples that are likely to be highlighted in subsequent NCSBN publications, so stay tuned. In addition, in the future in this blog, we will be discussing ways to prepare students to demonstrate their clinical judgment competences through a variety of teaching strategies that tap into the same mental calculations as those required for NGN test items.
What does this new information mean for nurse educators in the United States and Canada?
During the presentation, the NCSBN emphasized that the Clinical Judgment Measurement Model (NCJMM) is developed to guide the measurement of test-takers’ clinical judgment competence. They recognize that there are many frameworks, including Tanner’s Clinical Judgment Model (2010), that can be used to support curricula and student learning related to clinical judgment. They also assert that the Nursing Process is analogous, in many ways, to the Clinical Judgment Measurement Model. In no way does the NCSBN require the use of the NCJMM as a curricular framework. So how can nurse educators use this information in preparing students?
Certainly, nurse educators must pay attention to the NCJMM in preparing students for the NCLEX and as a pathway to being a successful nurse. In my opinion, the emphasis on the development of clinical judgment provides nurse educators with a defined educational approach to deliver content and evaluate students. We know that when students engage in class, lab, and clinical activities that require them to think through the care they will provide, they are more likely to develop clinical judgment competencies that will serve them well not only on the NCLEX, but also in beginning practice. I believe that the NCJMM, particularly Levels 3 and 4, can provide an avenue for developing and using case studies in class, labs, and clinicals. It can also help us to construct discussions in class and develop or revise test items for our own tests.
Many nurse educators are worried that their schools do not have the learning management systems to provide students with experience taking these types of test questions. While this is a concern, I would suggest that if we focus on the clinical judgment process in all aspects of our teaching, we can meet the challenge of providing students with the necessary clinical judgment competence to be successful on the NCLEX. Besides, I suspect that publishers of standardized testing products and testing software see this as an opportunity for new business and will be working to provide us with testing products that more closely match the Next Generation NCLEX exams. My belief is that as nursing educators, if we focus on preparing students to make clinical judgments in class, labs, and clinical experiences, we will be preparing students for their future.