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Discussion

How much do NCLEX question writers have to justify their answers? I took a Kaplan...

course taught by someone who purportedly participated in the actual NCLEX question writing process at one point in her career. Time and time again she would reply when explaining the answer to a seemingly confusing question (one which the class clearly had a wrong answer that was less correct than other choices) with the mantra "the author felt". According to her there is an advisory board that reviews the questions, BUT the authors have final say.

The problem with this approach is that what is correct becomes at least partly a matter of the "authors opinion" rather than objective fact. Contrast this with the approach used in other fields. For example my father who was a an MD of Internal Medicine helped to write questions for the boards. He was REQUIRED to provide specific citations for ALL answers, and questions. Furthermore, these citations could only come from approved medical journals or texts. In addition, all questions were subject to rigorous review, and appeal. Much the same situation occurs with many major standardized tests such as the SAT. It is not uncommon to hear about a student who successfully challenges an SAT question. With the NCLEX we are not even advised of the specific questions that we miss or offered the opportunity to challenge the validity of the supposedly correct answer. Who audits these questions to ensure they are accurate and valid (not to mention "keyed" correctly)?

Here is an example of the type of question (one which supposedly appeared on an actual NCLEX exam) of which I am speaking:

The school nurse is teaching an accident prevention program to the parents of school aged children. Which of the following statements, if made by a parent to the nurse, indicates that teaching has been effective?

a. "I am going to make sure that my child wears a helmet, shin guards, and gloves when he rides his bike."

b. "I'm going to reinforce to my child our family's values about what we consider to be appropriate behavior."

c. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars."

d. " I am going to make sure that my wife and I observe our child when he plays outside with friends."

Answer: "C" according to the Kaplan instructor. Now almost everyone in my class chose "d" or "b". However, that's really not the point as you could make an argument for several of the answers. Instead, the point is that before someone can say that "c" is the correct answer they should have to cite a reference in approved nursing literature that justifies their position (for example a study published in the American Journal of Nursing that demonstrated a reduction in play ground injuries after teaching on the proper method to climb on monkey bars). Furthermore, they should have to show that the alternative answers are not equally supported in the "mainstream" nursing literature (thus if there were another study which showed that observing children while in play greatly reduced playground injuries then that would no be an acceptable "wrong" answer).

It is very possible that this one question may have caused a nurse somewhere, at some point tofail the NCLEX (and possibly lose her house due to the subsequent pay cut with her kids being taken to foster homes as a result). Call me sexist, but I do not believe that a male dominated profession would tolerate this sort of paucity of due process in something so fundamental to their futures.

Here is a possible solution. A sort of "Blue Book" of approved nursing knowledge should be authored by a panel of nursing experts at least every few years (think of Harrison's Guide to Internal Medicine for an example of what I am proposing). This would undoubtably be a multi volume set covering all aspects of nursing practice and would in turn reference many journal articles and studies in its index . However, it would provide a "starting point" for what was most important for a nurse to know. Then, it should be a requirement that every NCLEX question (and I would argue nursing school exam question from an accredidated school) MUST reference the page number which makes their correct answer, correct. Although, one might disagree with The Book answer, at least there would be an objective reference that wouldn't waiver with the opinions and experiences of the particular question writers.

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Excellent post, and point, Roland. I doubt that this would be a burning issue to anyone but nursing students and people who fail the NCLEX and suffer the consequences because of questions such as this.

I have not been an NCLEX item writer, but I have written questions for national nursing certification exams. The process for item writing for these exams was exactly as you describe in your post. I disagree with the item-writing process that the Kaplan instructor told you, but I do agree that C was the best answer for the NCLEX question for other reasons. My reasoning is based on experience as an NCLEX and test-taking tutor.

The key words/concept in the question is accident prevention/evaluating teaching effectiveness. So in selecting the best answer you need to evaluate each response and decide if indeed this response speficially relates to accident prevent. To put it another way, you ask yourself "Will this response prevent an accident?"

Now look at each response and evaluate it according to the NCLEX question:

A. Not the best response because wearing this excessive amount of protection equipment will not prevent an accident. The head gear will help reduce the incidence of head injury should an accident occur while bike riding, but it won't prevent an accident. In addtion the other protective gear is beyond what is necessary for bike safety.

B. Not the best response, because the family's values about appropriate behavior doesn't guarantee safety or prevent accidents. The nurse doesn't know from the wording of this statement that the family's values are in fact safe. Some families don't think bike helmets or seat belts are necessary.

C. Best answer from the four choices because this is the only response that includes specific "correct" way to use a potential safety hazzard (monkey bars). If the child is properly instructed on safe use of the playground equipment, then in theory this can prevent injury (that would occur from unsafe/improper use of the equipment).

D. Not the best response because observation will not prevent injury. You could watch the child as they fall from the monkey bars.

For better or for worse this is how one has to approach answering NCLEX questions. You select the best answer, which is based on critical thinking and application of nursing knowledge and scientific principles. When you apply those concepts to the example question you provided you find that C is the best answer from the four possible choices.

  • Author

Again, the point was that for the question to be correct the author should be able to cite objective evidence in the form of journal articles, studies ect. Specifically, many of us avoided answer "C" because many schools now view "Monkey Bars" as intrinsically dangerous (which is why you see them less and less often at public playgrounds). Therefore, just as you wouldn't instruct your child on a "safe" way to smoke cigerettes or ride in a 1972 Ford Pinto you wouldn't instruct your child to play on something now seen as hazardous. On the other hand many parents can cite real world examples of where actually watching their children play (and judiciously interrupting) quite possibly prevented a serious accident. Just yesterday I was watching my son play at a McD's PlayPlace when the children suddenly started a game of high speed "tag" OUTSIDE the contained play area. I stepped in and stopped the dangerous game before someone could slip and crack their skulls on one of the tables. Now despite my personal experience, I wouldn't have offered this as a correct answer to that test question unless I could provide an academic reference from a Nursing Journal or study to support my position. Note that this question was one of many similiar questions where the Kaplan instructor said that although even she disagreed with the answer that "the author felt..." it was correct. My ponit is that no matter how many PhD's you have behind your name you don't get to "feel" anything. Everything must be referenced, supported, and substanciated to the point where a "reasonable nurse" would agree with your conclusions. It will probably take a few class action law suits aimed at this issue to effect any sort of significant change in my opinion.

I have not been an NCLEX item writer, but I have written questions for national nursing certification exams. The process for item writing for these exams was exactly as you describe in your post. I disagree with the item-writing process that the Kaplan instructor told you, but I do agree that C was the best answer for the NCLEX question for other reasons. My reasoning is based on experience as an NCLEX and test-taking tutor.

The key words/concept in the question is accident prevention/evaluating teaching effectiveness. So in selecting the best answer you need to evaluate each response and decide if indeed this response speficially relates to accident prevent. To put it another way, you ask yourself "Will this response prevent an accident?"

Now look at each response and evaluate it according to the NCLEX question:

A. Not the best response because wearing this excessive amount of protection equipment will not prevent an accident. The head gear will help reduce the incidence of head injury should an accident occur while bike riding, but it won't prevent an accident. In addtion the other protective gear is beyond what is necessary for bike safety.

B. Not the best response, because the family's values about appropriate behavior doesn't guarantee safety or prevent accidents. The nurse doesn't know from the wording of this statement that the family's values are in fact safe. Some families don't think bike helmets or seat belts are necessary.

C. Best answer from the four choices because this is the only response that includes specific "correct" way to use a potential safety hazzard (monkey bars). If the child is properly instructed on safe use of the playground equipment, then in theory this can prevent injury (that would occur from unsafe/improper use of the equipment).

D. Not the best response because observation will not prevent injury. You could watch the child as they fall from the monkey bars.

For better or for worse this is how one has to approach answering NCLEX questions. You select the best answer, which is based on critical thinking and application of nursing knowledge and scientific principles. When you apply those concepts to the example question you provided you find that C is the best answer from the four possible choices.

I agree with all of your comments/assessments of the NCLEX item writing process. However until such time as the correct answers are referenced as researched based (and I agree they should be!) those taking the NCLEX need to learn to decode the questions so in the words of NCLEX they can "select the best answer".

My example of breaking down how to select the best answer in no way supports that the question or best answer is appropriate. I just wanted to provide some pointers on how to determine the best answer from the NCLEX perspective.

I thank you for bringing up the topic of questioning the manner in which the NCLEX questions are referenced. Hopefully this will stimulate futher discussion and perhaps move the NCLEX in the direction of being a much better exam.

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