The New NCLEX®: Simulation is Not Optional

After attending the NCLEX® Invitational on Sept. 24 in Charlotte, North Carolina, one thing is clear: simulation is not optional.

The National Council of State Boards of Nursing (NCSBN) has done extensive research over the past 10 years on how effective the NCLEX assesses a candidate's readiness for practice. Based on their research and hard work, NCSBN developed a clinical judgment model of assessment. It explains that clinical judgment is the "DOING" part of critical thinking and clinical decision making.

Based on this model of clinical judgment, NCSBN is looking to create a series of question formats that are more like simulations than anything. There is talk about the student not only choosing the correct answer, but also giving rationale for the chosen answer.

NCSBN is also exploring question types whereby the learner has to take 10 patients and make room assignments. It's looking at the student highlighting parts of the electronic health record drug guide and highlighting the most important information for a nurse to consider when caring for a client in a certain situation. It is even looking at questions where students have to click on an image of a patient in a hospital room to identify a safety concern for the client.

These assessments are attempting to ascertain the level of the candidates' clinical judgment skills.

So how do we develop our students' clinical judgment skills?

NCSBN talks a lot about the learner forming habits. How does one form a habit? Through consistent repetition over time. Given that clinical judgment is the doing part of critical thinking, the logic points towards an increased need for simulation across the curriculum.

Beginning in fundamentals (the first semester of nursing school) the student should have many opportunities to immediately apply what is being taught in the classroom. This needs to start early and happen often (at least multiple times a month in many different ways).

There needs to be an increased emphasis on the students providing patient care during lecture. One of the best ways to do this is to borrow the simulation learning tools from the lab and have them in class. Run a simulation at the front of class and pause multiple times for the audience to write down the answer to "the nurse's next best action is …"

If simulation is not possible, use an unfolding case study. The whole purpose is that the students are creating the next steps for the nurse.

In the lab, it is essential that the students get access to multiple simulations each semester. These simulations should focus on key concepts (e.g. perfusion, gas exchange, etc.) rather than a particular disease process because this will better exercise students' clinical judgment muscles. Remember, NCLEX has always been conceptual – this will grow even more with the increased emphasis on clinical judgment.

Given that many believe debriefing is the most crucial part of simulation, this is an excellent opportunity for assessing and developing students' clinical judgment. Remembering that clinical judgment is the "doing" part of critical thinking, the students should be asked to pick two to four important parts of the simulation and give rationale for their actions at that point in the simulation. Regardless of whether their actions were correct, questionable, or totally wrong, when they develop rationale, clinical judgment is the emphasis.

One final strategy to remember when it comes to building habits of clinical judgment is continuously addressing students' personal gaps in knowledge. The students must be continuously evaluating where they are with their own personal knowledge base to fully engage in simulations in class, lab, or even actual patients in clinical. The best way to do this is by having students use an adaptive quizzing tool daily, if not multiple times a week. Students should quiz themselves based on current concepts being taught in class. They should know right away if they have gaps in understanding and address those gaps shortly thereafter. By addressing their knowledge gaps on a frequent basis, this will amplify the enduring learning from the simulation experiences.

While it is important to note that we are a few years from seeing these new test items fully implemented, it is clear there is increased focus on clinical judgment on the NCLEX that requires nurse educators to consider how to make simulation more of a focus in all learning environments. This takes a bit of imagination but essentially the focus is allowing students to do something with the concepts they are learning in a timely fashion.

Tim Bristol,


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