Next Generation NCLEX: Are You Ready?

SafetyNurse1968, ADN, BSN, MSN, PhD

A little history (we aren't changing the NCLEX just to torture you!):

50 years ago, when the nursing process was first defined, nursing was much more task oriented and basic. We've evolved and the National Council of State Boards of Nursing (NCSBN) is taking steps to ensure you are ready for your first job as a registered RN with clinical judgment skills that will ensure optimal patient outcomes and prevent medical error.

The NCSBN found that 60% of new nurses were making errors related to clinical judgment and about half of those errors led to remediation of disciplinary action. There's no data on how many of them might have led to patient harm.

What is clinical judgment?

"The observed outcome of critical thinking and decision-making"

You are going to need to:

Observe and assess presenting situations
Identify prioritized client concerns
Generate the best possible evidence-based solutions to deliver safe client care.

It's a six-step process that includes: recognizing cues (assessment), analyzing cues, prioritizing hypotheses (diagnosis/analysis), generating solutions (planning), taking action (intervening) and evaluating outcomes.

Timeline

Since 2017, select candidates have received a Special Research Section of questions at the end of their NCLEX exam – these questions had no impact on scores but provided valuable evidence for the efficacy of the questions.
In April of 2022, some of us will get to take the NGN and provide feedback. I hope I get to try it!
Live testing will happen in December of 2022 – select new grads will take the NGN, but their results won't count. Maybe you'll be asked to participate?
April 2023: NGN Launches!

Changes

The NGN will present 70-135 scored items based on your ability.
You will respond to three case studies. Each case study will present six items designed to assess clinical judgment. 3 x 6 =18 clinical judgment items.
You will answer a minimum of 52 knowledge-focused items. Total: 18 clinical judgment items + 52 knowledge-focused items = 70 items
You will be asked 15 items that will not be scored and will be used for future item development.
After answering the initial 70 items, if you are close to the cut score, you will be asked additional questions. Most of these will be knowledge-based, but about 10% will focus on clinical judgment in the form of stand-alone items. The maximum number of questions you can get is 135 (+15 unscored items).
It's exciting to know that the NGN will include partial-credit scoring for some of the new item types.

Computer Adaptive Testing (this hasn't changed)

This method of administering both the NCLEX and the NGN combines computer technology with measurement theory to conduct exams more efficiently.
When an item is answered, the computer continuously re-calculates your ability based on all the previous answers and the difficulty of those items.
The computer selects the next item that you have a 50 percent chance of answering correctly.
The computer's estimate of your ability becomes more precise as more items are answered.
When the computer establishes your ability, the examination ends.
The Cut Score marks the minimum aptitude required to safely and effectively practice nursing at the entry-level. The computer stops administering items when it is 95 percent certain your ability is either clearly above or clearly below the passing standard.

What can you do?

Rest assured, I'm an instructor and I'm working hard to ensure that your classroom experience is geared toward success on the NGN, but you can get a head start by advocating for yourself.

Clinical reasoning is best learned through experiences in both clinical and simulated environments – seek out simulation!
Seek out one-on-one interactions and personal dialogue with your instructors
Look for opportunities to interact with other healthcare team members
Ask "what is most important here?”
Actively engage in class – whether it's virtual or in-person – your instructors are designing active learning experiences for you that promote higher-level thinking
Don't expect to passively listen to a lecture – you need to show up having already engaged with the material so you can participate.
Try thinking out loud – talk through your problem-solving process and ask your instructors and the nurses you are working with in clinical to do the same. Ask, "How did you figure that out?”
Ask for timely and specific feedback that identifies your strengths and deficits and always ask, "How can I improve?” Being defensive won't get you far – find ways to adopt a growth mindset in which you welcome constructive feedback.

New NGN Items

The majority of the items will be the standard NCLEX item types, so I'll focus on those, but I will also be digging into NGN items (these can be attached to a case study or be stand-alone):

Matrix multiple-choice
Matrix multiple-response
Multiple-response: Select all that apply
Multiple-response: Select N
Multiple-response: Grouping
Drag-and-drop: Cloze
Drag-and-drop: Rationale
Drop-down: Cloze
Drop-down: Rationale
Drop-down: Table
Highlight: Text
Highlight: Table.
Bow-Tie
Trend

Sample Question

Priority setting will remain a big deal! You have the tools, you just need to use them: Maslow's hierarchy, the nursing process, Airway-Breathing-Circulation, Safety & Risk reduction, least restrictive/least invasive, acute vs. chronic/stable vs. unstable/urgent vs. nonurgent. If you can master these tools to prioritize care – you will pass the NGN with no problem, but you can't do it without practicing. When you are in clinical or simulation, don't be afraid to ask, "How did you decide what to do first?” Maybe you're shadowing a nurse on a busy unit – ask her, "How do you decide which patient to see first?”

A 16-year-old patient complains of excessive lady partsl bleeding. Which action would the nurse perform first?

A serum pregnancy test
Referral to an oncologist
Education about oral contraceptives
Obtaining an order for a hysteroscopy

What priority-setting tools can you use to answer this question? The first thing I think of is the nursing process – which of these questions are assessments? I can eliminate #2 and #3 because those aren't assessments. I can then use the "least invasive" rule to choose #1 as the best answer. You can actually answer many questions using priority-setting tools without even knowing anything about the underlying physiology (though I do recommend knowing that as well!)

This is just one sample question – I'm planning on including many more in the coming years, but I could use your help. What would you like to see more of? What kinds of practice questions are most helpful?

References

ATI testing resources for NextGen NCLEX

NCSBON info about NextGen NLEX

Getting Ready for the NextGen NCLEX