Susan Sportsman, PhD, RN, ANEF, FAAN
April 2023 marks the first time that new nursing graduates complete the Next Generation NCLEX (NGN) Examination. The results of the work of the National Council of State Board of Nursing (NCSBN) in developing the NGN and the responses of nurse educators who are preparing students for this innovative licensing approach will be documented in the test results over the next year. All nurse educators and regulators are hopeful that the NGN will more accurately differentiate among new graduates who are prepared to make clinical judgments required for today’s nursing practice and those who are not. In addition, everyone hopes that THEIR students will be successful. Despite the preparation of the regulators, nurse educators, and new graduates, we are likely to have a better idea of the extent to which new graduates are ready for clinical practice as data from the test results are collected throughout 2023. What interventions by nursing education might be necessary to ensure student success as we move through this new challenge?
Background
The 2013-2014 NCSBN Strategic Practice Analysis, which provided an understanding of the clinical expectations of new nursing graduates, found that because of the complexity of the healthcare environment, new nurses were required to make much more complex decisions while caring for patients than in the past (NCSBN, 2019-2022).These results, along with an extensive literature review, informed the development of the Next Generation NCLEX project.
Clinical Judgment Measurement Model (CJMM)
The Clinical Judgment Measurement Model (CJMM) serves as the basis for the Next Generation NCLEX Examination. Although in the past, questions presented in NCLEX exams required students to apply nursing knowledge to clinical scenarios, the development of this model illustrated the relationship between the unseen behaviors of critical thinking and problem-solving and clinical judgment, which can be observed. This description and the steps students must take to use clinical judgment provide nurse educators with strategies to develop teaching-learning activities and evaluation processes that emphasize students’ clinical judgment competence. The steps in the Clinical Judgement Measurement Model are similar to the steps in the Nursing Process, although perhaps more concrete and observable. The comparison of the steps of these two concepts are outlined in Table A below.
Table A: Comparison of the Steps in the Nursing Process and the CJMM
| Nursing Process Steps | CJMM Steps |
| Recognize Cues | Assessment |
| Analyze Cues | Analyze |
| Prioritize Hypotheses; Generate Solutions | Plan |
| Take Action | Implementation |
| Evaluate Outcomes | Evaluation |
https://nclex.com/clinical-judgment-measurement-model.page
Environmental Factors Influencing Student Development
While the NGN was being developed, the Covid pandemic upended healthcare and education. The multiple stresses from this period resulted in a drop in the average NCLEX score for first time U.S. test takers between 2019 and 2022, although in 2022 an uptick in the PN scores were seen (NCSBN, 2019-2022). This drop in the first-time scores requires nurse educators to consider more targeted strategies to effectively support students’ development of clinical judgment competence in a variety of clinical situations. What strategies might nurse educators implement that will prepare students for the NGN and the complex healthcare system?
Educational Strategies for Success
The focus on clinical judgement must be integrated throughout the curriculum. Regardless of the course—Fundamentals, Med-Surg, Family Health, Pharmacology—the curriculum, teaching- learning processes and student evaluations must require students to use the knowledge and skills of the specific course to formulate, implement and evaluate nursing care in specific situations. Here are some examples of strategies you might consider to ensure that the focus of nursing education is on clinical judgment.
Curriculum Evaluation
A thorough evaluation of the nursing curriculum to determine the integration of clinical judgment throughout is key. Table B provides a checklist that will shed light on the extent to which the emphasis on clinical judgment is documented throughout the curriculum, thus providing a guide for all faculty and students.
Table B: Clinical Judgement Curricular Checklist
| Criteria | Yes | Somewhat | No | Notes |
| Do the Program Goals (Student Learning Outcomes) include competence in Clinical Judgment? | ||||
| Are course objectives in each nursing course written at the application level or higher? * | ||||
| Do the course, lab, simulation, and clinical objectives require the use of clinical judgment to demonstrate competence? * | ||||
| Is the Clinical Judgment Measurement Model taught early in the course of study, paired with the introduction of the Nursing Process? | ||||
| Do the majority of teaching-learning activities in class, lab, simulation, and clinical experiences require the practice of clinical judgment? | ||||
| Does students’ written work (care plans, case studies, etc.) document their use of clinical judgment? | ||||
| Do clinical evaluation forms require assessment (faculty and self-evaluation) of clinical judgment? |
*Note which courses do not meet the criteria, so that follow-up can be done.
Click here to view and download the clinical judgement curricular checklist. Once the curriculum as a whole is evaluated, faculty should determine the extent to which their expectations of student competence in didactic class emphasizes clinical judgment. Here are some teaching tips that should help.
Classroom
- Require students to read texts and use relevant resources to understand the basic content areas before they come to class. (I know—students do not want to read before they come to class.) However, if they must have sufficient knowledge to participate in class activities, they are more likely to prepare for class. Here are some ideas for how to encourage such preparation.
- Use short pre-tests or quizzes (less than 5 questions) at the beginning of class. Because most students are more likely to prepare if the test “counts, some sort of grade should be given.
- Use the early part of class to allow students to ask questions for clarity about the materials. (5 minutes or so). If there are no questions from students, call on students to explain a part of the text that you know to be challenging. This allows you the opportunity to explain areas that are typically difficult for students.
- Completely give up the notion that you are going to spend the entire class period lecturing to students! You may need to provide short (20 minutes or less) explanations throughout class, but do not spend the entire class giving students all the content they will need.
- Give students the opportunity (individually, in small groups, or the entire class) to use clinical judgement in particular scenarios. You may identify for them the step(s) in the CJMS they should focus on (for example: Recognize Cues) or you may want them to work through the problem completely, using all steps in the CJMM.
- Ask students to explain the rationale for the decision(s) they made. Engage all students in a critique of decision-making process used.
- Provide an opportunity for students to reflect upon their own work, including additional information they might have needed to make good decisions, and tactics for identifying such information.
- Close class with a discussion of how to answer one or more NGN Style questions on the topic for the class.
Skills labs
Never have students practice a skill without having an accompanying scenario to put the skill(s) in context. For example, you may want students to change the dressing on a wound, using a moulage. Despite the lack of a “real patient”, you can give students a brief history of a “patient with a wound”. After the student completes the dressing change, ask them “what if” questions such as:
What if
…. you broke sterile technique while placing the gauze pad on the wound?
…. you see purulent drainage seeping through the bandage?
….the patient complains of severe pain?
This approach prevents the skill from being disconnected from the prime role of the nurse which is to provide safe care through effective clinical judgment.
Certainly, students also develop clinical judgment competencies through clinical assignments, faculty made tests, remedial work based on data from standardized tests and clinical evaluations, but those are topics for another blog. In the meantime, good luck as you navigate this first year of the NGN examination. I would love to hear your experiences!
To read more about the Next Generation NCLEX Examination, go here.
References:
National Council of State Boards of Nursing. (2021) Clinical Judgment Measurement Model. Accessed 2023. https://nclex.com/clinical-judgment-measurement-model.page
National Council of State Boards of Nursing (2022,2021, 2020, 2019) NCLEX Pass Rates. Accessed, 2023. https://www.ncsbn.org/exams/exam-statistics-and-publications/nclex-pass-rates.page
National Council of State Boards of Nursing (2013) Strategic Practice Analysis. Accessed, 2023. https://www.ncsbn.org/publications/Strategic-Practice-Analysis