New NCLEX Exam to Replace Nursing Process With An Untested Clinical Judgment Model

BrentRN, PhD · Jul 1, 2019

1 hour ago, pmabraham said:
Why go from evidence-based practice to non-sense that doesn't happen clinically in the field?

I am not sure of what you are asking here. Please elaborate. Thanks.

joe007 · Jul 2, 2019

I think the NCLEX and nursing program I was trained in was BS to begin with. Essentially, most NCLEX questions can be answered by either studying Kaplan or some other test prep materials. My nursing school dean admitted to me that only 70% of our material was presented in the material (about 500 pages of reading per test of which we had four tests every two weeks) and that the other 30% of questions from their test bank were "experimental questions." AKA, no incentive to read the book and understand nursing in a comprehensive manner because doing so was non-feasible given time restraints, but there was much more of an incentive to do random questions on ATI, Kaplan, end of chapter reviews, etc. I passes NCLEX in 2013 with 75 questions and a 3.8 GPA because I understood how the game was played. However, I am a second degree student and believe that if nursing was taught as a comprehensive subject where one draws associations in their answers between clinical presentation and clinical action in a comprehensive scenario to ensure nurses actually understand the depth and width of nursing practice, the nursing workforce would be much better prepared than the "pick the best answer" type model the NCLEX is. Essentially, the NCLEX and nursing school is an IQ test in my opinion. My instructors told me that we need not worry that much about being that great at nursing because "you'll learn when you get hired." My professors also bragged about our program having the highest NCLEX pass rate in the state.

Ruth Hansten · Jul 10, 2019

I agree with the concerns that Rosalinda Alfaro-LeFevre is raising. Having studied critical thinking/clinical judgment for my dissertation research and having worked with about 180 organizations as a consultant/educator it is very clear to me, from a practical standpoint, that the most logical, iterative blueprint for our practice is ADPIE, the nursing process.

steven007, BSN, MSN · Jul 18, 2019

I don't want to be the cynical one here, but I am having a hard time seeing how this really meaningfully impacts new nurses? Part of the issue is that I am a Canadian nurse, but Canada now uses the NCLEX as well. I have taught the nursing program and most of the students had no idea what the nursing process even was! The emphasis of the particular program I taught in was Henderson's theory. No attention was paid to ADPIE.

Now, I am a strong proponent of ADPIE. I use it in my daily life. It is how I chart my end of shifts documentation notes, I use them as headings. But I don't think that it is the ONLY valid and applicable framework to use.

Also, while I agree with most of what BrentRN, PhD says, I disagree in the emphasis on validation. The nursing process, while heavily used and discussed in the research, is not a "validated tool". There is no metric to validate. It is a subjective FRAMEWORK used for a subjective ASSESSMENT. It is by no means a valid scale that is measuring any meaningful data. There is really no research that I could find on the nursing process being any more effective than just using common sense. There is nothing about the nursing process that can be operationalized into a numeric scale that can be statistically tested. So the argument of validation is completely irrelevant.

Furthermore, most senior nurses and even new nurses I ask don't even know what the nursing process is! They have no idea what ADPIE is. I think, at least in Canada, most schools just pick a nursing philosophy they like (i.e. henderson, oren, etc) and go with that. There is no real emphasis placed on using a framework.

On that note, I do find the nursing process very intuitive. It is basically just common sense, you assess, diagnose, plan, implement and evaluate. It couldn't be any more straight forward! I think replacing it with a more convoluted theory/framework is counter-intuitive and unnecessary and serves no real purpose. If it isn't broken, don't fix it.

I'm curious as to the rationale of why they are doing this now? Bearing in mind that times change, culture changes and society changes. I find that, at least in medicine and nursing, they try to find new ways to conceptualize old theories and it is just pointless and a waste of resources that would be better spent on theorizing on more meaningful and pertinent topics.

Ruth Hansten · Jul 18, 2019

Hi! So often the discussions of the educators or other organization leaders do not really seem so relevant to actual nursing practice-- I agree.

I think people may see the nursing process (the scientific method used by nurses) and nsg theories/philosophies (orem etc) to be separate entities? (I cannot really comment on this b/c my further ed is not on those particular topics!)

But I do believe that ADPIE is basic to nursing as a profession.

I think that expert nurses (whether Canadian or US or anywhere) have used the ADPIE process but may not be aware that they are using it. because experts find themselves to quickly "see" the clinical picture and act intuitively --almost instantly-- and are not aware that they were actually using ADPIE. They quickly saw that X hypothetical patient was in pain (assessment) though clinical signs and data, diagnosis/planning occurred with patient verification of pain level and discussion when possible, they acted (ice/reposition/meds or whatever) then they evaluated whether or not their interventions were effective. I am betting if you asked your friends what they "do" when they are thinking about X patient, they would perhaps be able to verify that they did in fact use that process! It would be fun to ask them. I have discovered that often they are unaware they are using it.

thanks for your comments!

Crash_Cart · Jul 18, 2019

Translation:

If it ain't broke, don't "fix" it.

gere7404, BSN, RN · Jul 19, 2019

I skipped the instructions for the research questions because I was just stoked the computer shut off at 75 questions. They were incredibly difficult to understand, so I quit out of them thinking "how bad would it be to have to take the entire test like that?"

Poor bastards graduating in 2022!

Daisy4RN · Jul 19, 2019

15 hours ago, gere7404 said:
I skipped the instructions for the research questions because I was just stoked the computer shut off at 75 questions. They were incredibly difficult to understand, so I quit out of them thinking "how bad would it be to have to take the entire test like that?"
Poor bastards graduating in 2022!

I agree that at the end of the NCLEX is probably not the best way to have "research" done. People will be stressed and tired and either blow off the questions completely or just mark anything to get out of there. Not going to get good results/data that way!

BrentRN, PhD · Jul 19, 2019

2 minutes ago, Daisy4RN said:
I agree that at the end of the NCLEX is probably not the best way to have "research" done. People will be stressed and tired and either blow off the questions completely or just mark anything to get out of there. Not going to get good results/data that way!

You're absolutely correct, yet the NCSBN touts their research as the reason for going ahead with the changes.

BrentRN, PhD · Jul 19, 2019

On 7/17/2019 at 8:07 PM, steven007 said:
I'm curious as to the rationale of why they are doing this now?

Their reported reason for doing it is that something like 50% of all nursing errors are committed by first year nursing students. They have concluded, without published evidence that I can find, that the licensure exam must be to blame.

The long stated purpose of the exam is to assure the public that the candidate can perform safely at the level of a beginner nurse. That is all that it tests. It does not test all the other things that make one a good, well-rounded, and well-educated nurse.

An expectation of safe practice is the ability to critically think in nursing situations. Safe nursing obviously is more than efficient task performance. ADPIE is a tried and true way to guide the beginning nurse through clinical judgments.

Unfortunately, many nurses do not recognize they are using a nursing process, or what framework guides their practice.

The dirty secret of nursing is that there is not one universally accepted definition of nursing. There are lots of competing and overlapping definitions but none that succinctly capture the roles of the nurse. That is the reason we live with so many competing frameworks, and nurses who cannot define basis of their practice.

Crash_Cart · Jul 19, 2019

2 hours ago, BrentRN said:
The long stated purpose of the exam is to assure the public that the candidate can perform safely at the level of a beginner nurse. That is all that it tests. It does not test all the other things that make one a good, well-rounded, and well-educated nurse.

Entirely agreed.

Successful completion of an NCLEX exam is only intended to be the starting point, not the final conclusion.

Only real world experience can be the measuring stick of any such final conclusions.

Rosalinda Alfaro-LeFevre · Jul 20, 2019

On 6/28/2019 at 6:04 PM, kbrn2002 said:
Thank you for clarifying the particulars of this. I was about to do the same and saw you already responded. I am a panel member for the NCSBN and have participated in sessions regarding this new format. While I can't go into any particulars due to confidentially agreements I will say the test questions we have worked on are not such a departure that it is an entirely new concept in testing. The NCSBN website links provided by NRSKarenRN are the place to go for official information.
As mentioned this is still in the testing phase. The students that are presented with a section of questions using the new format will receive them after they have already completed the actual test. These new questions are not scored. They are there to compile data collected from actual test takers that will be extensively studied before any changes to the scored test are implemented.
I don't think it breaks any of my confidentiality agreements to say this is not new for the NCSBN. Part of the exam writing process involves inserting non-scored questions in the NCLEX exam before they are included as part of the official test bank as well as evaluating questions that are already in the test bank to ensure they remain relevant to current practice.

On 6/29/2019 at 3:07 AM, BrentRN said:
The problem is that the tested questions are simultaneously assuming the CJM is valid and that the questions validated the CJM. That is circular logic.
Imagine this analogy:
Suppose I have a theory that homeopathic medicines are using "quantum level force" that cures headaches. I then give my headache patients the medicine and find that about half the time the headache goes away within a few hours. Did I just prove "quantum level force" cures headaches? Of course not. Without a mechanism for how the force relates to headaches just showing good results does not confirm the force exists.
This is just why the NCSBN cannot say their research is validating the CJM. The other problem is that the secrecy of the NCSBN keeps anyone from seeing their data, or even discussing their methods. We are just supposed to believe them but that is not how science works.

Thank u for the above! I agree. Part of this issue is that the NCSBN makes their communications look like all is great with their process, so many think it’s a great idea.

At a closer look there many issues, not only with the CJM (as Pat Benner and I both independently noted), but with the research section: Increasingly, NCLEX takers are reporting that the felt they HAD to complete the test, but were too tired by then. So they clicked away without much thought to the questions. ThIs calls into question how they can be so happy with the research section results. Coincidence?

I’m new to this group and am struggling a bit with how to reply. I hope I did this right. If not, since I’m out of the country, can you re-post for me?