In this Q&A, Elsevier NGN experts Donna Ignatavicius and Linda Silvestri answer common faculty questions regarding the Next Generation NCLEX.
As educators, how do you see the NGN changing the classroom for both faculty and students and how can faculty make sure they’re adapting their classroom to these changes?
It is important that our classroom sessions integrate teaching-learning strategies that promote “thinking like a nurse” activities to support the development of clinical judgment. Classroom sessions should not be purely lecture-based. If they are, then this is one change that needs to be made.
Students need to be participating in active learning exercises in the classroom or online. Many nursing programs are using interactive strategies. We recommend considering the use of a scrambled classroom approach as a way to support the long-term memory (deep learning) and retrieval learning. Scrambled classroom approach also helps students learn how to use knowledge to develop clinical judgment for NGN success. This is a stimulating method of learning that mixes lecturettes (5- to 10-minute lecture bursts) with activities, such as case studies and clinical judgment thinking exercises, followed up with debriefing sessions.
When selecting clinical judgment thinking exercises, select those that include case studies accompanied by NGN item types. Start with single case studies accompanied by an NGN item type that assesses selected cognitive skills, depending on the course and content being taught. For example, if you are teaching a health and physical assessment course you may want to focus on the cognitive skills, recognize cues and analyze cues. In the adult health courses, specialty area courses, and complex care course, include unfolding case studies that test all six cognitive skills.
Why is it important for the NGN to focus more on clinical judgment and how will this change impact the field of nursing and future nurses?
The criticality of competent clinical judgment skills in nursing is not a new concept. Benner et. al. (2010) notes that nurses entering practice do not know how to use the knowledge and skills needed for today’s dynamic and complex health care environment.
More recently, increased attention has focused on the ability of the new nursing graduate to make sound clinical judgments in the care of patients. Research indicates that only 23% of new nursing graduates are competent in basic clinical reasoning and judgment skills (Kavanaugh & Szweda, 2017). Additionally, the National Council of State Boards of Nursing (NCSBN) reports that 50% of patient errors involve nurses and 80% of employers are not satisfied with nursing graduates clinical judgment skills (NCSBN, 2018).
The current NCLEX-RN® and NCLEX-PN® measures minimal competency in safety and does not measure clinical judgment. These current exams focus on measuring content knowledge as either right or wrong rather than measuring clinical judgment skills. Incorporating test items that are valid and can reliably measure clinical judgment is critical and impacts the field of nursing and future nurses in many ways.
The NCSBN has been conducting robust research regarding clinical judgment and how it can best be measured on NCLEX. Based on their research, they developed the NCSBN Clinical Judgment Measurement Model (NCJMM). Additionally, their research focused on the item types that measure specific cognitive skills necessary when making a clinical judgment. The NCSBN continues to conduct research on this process and information about their work can be located at their web site at www.ncsbn.org. We encourage faculty to access their web site on a regular basis to remain updated on their progress. Finally, we would like to say that it is absolutely necessary that nurse educators prepare nurses that are able to think in action and make clinical judgments. It is the responsibility of the profession to ensure that the people we serve are protected and provided with safe and competent health care providers. Thus, the NCLEX must focus on measuring clinical judgment.
What should faculty pay attention to when planning their curriculum to incorporate more NGN concepts?
First, it is important to be familiar with the NCJMM and ensure that your nursing students are familiar with the cognitive skills in Layer 3 of the model. We are not saying that your curriculum needs to be restructured or that this model should be the sole clinical judgment model guiding your course development, but what we are saying is that familiarity for both faculty and students is important to best understand how the NCSBN will measure clinical judgment.
Next, collaboration among faculty about the plan for incorporating NGN concepts is very important. Faculty need to have consensus on the curriculum process regarding “the what and the how” to promote student learning and thinking, and incorporate strategies to promote and encourage retrieval learning.
It is necessary to remember that case studies are the basis for the new NGN item types. Both single episode case studies that measure one or possibly more cognitive skills and unfolding case studies that measure all six cognitive skills of the NCJMM will be presented on the NCLEX. With this in mind as a starting point, it is important that you use case studies as a teaching-learning strategy in class and in clinical to promote thinking like a nurse and enhance clinical judgment skills.
Do you find value in faculty-led post-exam reviews with students? What about having students complete a missed-item analysis assessment after each of their exams?
There is value in faculty-led post-exam reviews with students. Reviewing exams allows the student to identify areas of strength and weakness and become aware of how to improve on future exams. Self-assessment is always a valuable exercise for students; post-exam reviews also help students become aware of what they do and do not know about the specific content tested. Post-exam review sessions also provide the opportunity for faculty to implement a scrambled classroom strategy. For example, as exam questions are reviewed and item analysis indicated a concern for a particular question, faculty can provide a lecturette on the content of that particular question. This can be followed-up by Socratic questioning, perhaps about what the implications could be for the patient if each incorrect option for the test question was selected. If time for review of an exam is a concern, consider focusing on the problematic areas noted in the item analysis. An additional option is exam review during office hours.
Is there a template faculty can use to develop NGN items?
We prepared guidelines for developing single episode and unfolding case studies. We also prepared templates for creating each NGN item type associated with each cognitive skill. We anticipate some updates from the NCSBN late fall and in the beginning of the spring semester. Once updates are known, these guidelines will be revised as appropriate and shared with faculty. We are also planning some faculty webinars to present the process of NGN item writing for each NGN item type. Stay tuned to the Elsevier site for the dates and time of these upcoming webinars.
In regards to blueprinting exams, will the current test plan categories go away or will NGN NCJMM be integrated with what is currently in the plan? If faculty are creating new test items should they include current NCLEX categories as well as future NCJMM labels?
According to the NCSBN, the test plan framework with regard to Client Needs and any subcategories is expected to remain the same. Every three years, the NCSBN conducts a practice analysis study, one study is for the RN and a separate study for the PN, to determine the framework for each NCLEX test plan. Therefore, it is important to frequently access the NCSBN website at www.ncsbn.org for the most updated information.
The NCJMM will be integrated in the test plan. Case studies and associated NGN items will be developed based on a Client Needs category and subcategory as appropriate and based on the activities lists in the plan. For example, an activity statement in the test plan may read: apply knowledge of pathophysiology to monitoring for complications. If you’re teaching gastrointestinal content, then you could develop a learning outcome of: identify potential complications for clients who have chronic inflammatory bowel disease. To measure this learning outcome, you could create a single episode case study and develop an NGN item that measures the cognitive skill of Analyze Cues.
One additional, important point that we want to make is that the types of items currently used on NCLEX will still be a primary part of the exam. You need to continue to create your course tests including primarily these item types (i.e., multiple choice, select all that apply, fill-in-the blank and others).
Should there be an attempt to coordinate the final test(s) from the previous courses with the initial assessment test(s) of the current course(s)? If yes, how so?
Retrieval knowledge is the ability to bring previously learned concepts to mind and apply these concepts to new content and situations. Retrieving knowledge forms the foundation for new learning. As nurse educators we need to encourage and foster retrieval knowledge and challenge students with opportunities to do so. Students need to be aware of the value placed on retrieval knowledge and that it is an expectation in their program of study.
One strategy to foster retrieval learning is to coordinate exams throughout the program so that selected questions on final exams from previous courses are used to create a pre-course assessment test for a new course. Faculty then would administer a pre-course assessment test at the beginning of every new course. To emphasize the value placed on retrieval knowledge, the exam should be scored and count in the course grade. Faculty could collaborate and create these pre-course assessment tests based on previous courses. The exam does not have to be a lengthy exam, or it can be – based on faculty preference – and again would be made up of questions that test content that students learned in previous courses.
Are there resources to help with analysis of responses to NGN type questions for faculty using psychometrics to analyze multiple choice test items?
The NCSBN is currently conducting research on the psychometrics and analysis and scoring of the NGN test items. NCSBN decisions have not yet been made, so presently we are not aware of resources to help with the analysis of NGN items. The NCSBN strives to keep faculty informed of any updates and decisions made. These updates can be located at their web site at www.ncsbn.org. We encourage you to access their web site on a regular basis to obtain the most updated information.
I teach in the first semester licensed practical nursing (LPN) Fundamentals of Nursing course. How many NGN questions should I be including in the first exams? We have a 75% understanding and 25% application and analysis exam.
It is great to hear that NGN items will be included in the Fundamentals of Nursing course. It is important for students to have practice with these item types in their first nursing course and every course thereafter. It is necessary to remember that the types of items currently used on NCLEX will still be a primary part of the exam. So you need to continue to test using these item types (ie. multiple choice, select all that apply, fill-in-the blank and others) and the majority of the exam should be comprised of these types.
The NGN items that you do include in your exams need to be designed to test at the analysis, application, or higher cognitive levels. Currently, the NCSBN plans to administer two to five unfolding case studies and some number of single-episode cases that meets the adaptive testing process. Therefore, as a starting point, you may want to consider including two single-episode cases, each accompanied by an NGN item type in each fundamentals of nursing exam. Then, as the student progresses in the program to adult health and specialty courses include one to two single-episode cases, each accompanied by an NGN item type, and at least 1 unfolding case accompanied by 6 NGN items to measure all six of the cognitive skills.
Will nursing programs have the sole responsibility in preparing the students for the NGN items? Is there a known process for schools to use in adapting their curriculum for NGN items? What resources are available for students and faculty to prepare for NGN?
Nursing programs are responsible for preparing students for NGN items. While there is not a specific step-by-step process, there are known ways and resources available to you to implement in the curriculum.
Program outcomes need to focus on preparing a graduate who is a safe and competent care provider. Encompassed in that outcome is preparing a graduate who has strong clinical judgment skills. The need to foster these skills in our nursing students is not a new responsibility for nurse educators; we just need to bring this skill to the forefront of our teaching and learning strategies and have this skill be a priority outcome across the curriculum for all nursing courses.
Elsevier offers many solutions to help faculty prepare students for the NGN. It is important to remember that students need to be familiar with the NCJMM and with the various item types that they will be challenged with on the NCLEX. Familiarity with what to expect can decrease the anxiety and stress associated with the NCLEX. With that being said, ensure that you provide your students opportunities to prepare.
We recommend that you review the student workbook written by Donna Ignatavicius titled, Developing Clinical Judgment for Professional Nursing Practice and Next-Generation NCLEX-RN® Success. This student workbook was recently published by Elsevier and includes numerous clinical judgment cases and thinking exercises for all courses, along with NGN item types. Additionally, Silvestri’s NCLEX Review resources provide practice with case studies and NGN item types.
Elsevier also incorporates practice opportunities for students with case studies and NGN items in many of their products, such as Sherpath. We encourage you to access the Elsevier Evolve Faculty Resources Website to view these many resources. Also, access the NCSBN website at www.ncsbn.org for NGN resources.
Finally, challenge your students by adding a single episode case study and one or two accompanying NGN items to your exams. However, be sure that you discuss as a faculty how you might grade these; you may want to include them on your exams as unscored items. We mention this consideration because it is important to remember that the NCSBN has not yet made any final decisions about how these items will be scored.
Barnett, P. E. (2014). Let’s scramble, not flip, the classroom. Inside Higher Education. Retrieved from https://www.insidehighered.com/views/2014/02/14/flipping-classroom-isnt-answer-lets-scramble-it-essay
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
Dickison, P., Haerling, K.A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78.
Gonzalez, L. (2018). Teaching clinical reasoning piece-by piece: A clinical reasoning concept-based learning method. Journal of Nursing Education, 57(12), 727-735.
Herrman, J.W., & Johnson, A.N. (2009). From beta-blockers to boot camp: Preparing students for the NCLEX-RN. Nursing Education Perspectives, 30(6), 384-388.
Kavanaugh, J.M. & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38(2), 57-62.