How to Align Your Tests to the New Next Generation NCLEX-RN® Requirements

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The wait is over! The Next Generation NCLEX-RN® (NGN) is FINALLY here. In today’s Osmosis blog, Senior Content Manager of Nursing, Elizabeth Lucas, EdD, RN, CNE, offers some helpful direction for aligning your nursing course exams to the updated NCLEX.

On April 1, 2023, after years of research and preparation, the much-anticipated Next Generation NCLEX-RN®, also called NGN, was officially launched. With this updated NCLEX comes changes to scoring, question formats, and, importantly, the inclusion of the NCSBN Clinical Judgment Measurement Model (NCJMM). This model was designed to measure a test taker’s ability to work their way from identifying a client’s needs to making clinical decisions (Layer 0) using the iterative process described in Layer 3 of the model: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes.

Developing Clinical Judgment

The best way to prepare students for the NGN is to give them many opportunities to practice their clinical judgment skills in each and every class, lab, simulation, and clinical.

Let’s use a respiratory assessment lab as an example. In a traditional lab session, you might ask each student to listen to wheezes, then rhonchi, and then crackles on the simulator manikin. Instead, you can alter this plan to help students develop clinical judgment by placing students into groups to listen to the different lung sounds which have not already been identified for the students. After auscultating the lung sounds, the student groups must answer the following questions:

Identify the type of lung sound you hear (recognize cues).

What other signs and symptoms might a patient with these lung sounds have (analyze cues)?
What might their vital signs and labs show (analyze cues)?
What, if anything, are you concerned about for this patient (prioritize hypotheses)?
Of these concerns, which are you most concerned about (prioritize hypotheses)?
What steps should be taken to prevent these issues (generate solutions)?
What should you do first, how will you do it, and what equipment will you need (take action)?
How will you know if the intervention you implemented was effective (evaluate outcomes)?

a. What will the patient look or sound like?

b. What will they feel?

c. What will their vital signs and labs likely show?

Once each group has had the opportunity to listen to each lung sound and develop their nursing plan, the groups compare their answers while you provide feedback and ask more questions to further enhance their clinical judgment development.

Assessing for Clinical Judgment on Your Exams

You may be worried that you have to completely start over with your exams to replicate the new scoring models and represent the new item types found on NGN. The good news is that this isn’t necessary or even realistic, especially during a busy semester! Like with teaching, focusing on clinical judgment will best help prepare your students for NGN.

You may already have many of the steps of the NCJMM represented on your exams. A great way to find out is by using a test blueprint or updating your current test blueprint if you already use one.

Item #	Program Outcome	Course Outcome	Bloom’s Taxonomy	Client Needs Category	NCJMM Layer 3
1	3	2	Apply	Psychosocial Integrity	Generate Solutions

Above is one example of a test blueprint that can be adapted to meet the needs of your program and course. In this blueprint, you are mapping each test item to a program and course outcome, assigning a Bloom’s Taxonomy classification, selecting the corresponding Client Needs category, and choosing the appropriate step of the NCJMM Layer 3.

The NCSBN website has excellent resources on the NCJMM, including this newsletter which breaks down each step of the NCJMM. You can ask yourself the following questions when determining which step of the NCJMM Layer 3 each of your exam questions fits into.

Recognize Cues

Recognizing cues is all about having the student identify relevant and important information from a variety of possible sources, like a patient’s vital signs, flowsheets, and medication records. Ask yourself, does the test taker need to:

Determine which information is relevant or irrelevant?
Determine which information is most important?
Select what information causes immediate concern

Analyze Cues

When analyzing cues, the student must organize and link the recognized cues to the patient’s presentation. Ask yourself, does the test taker need to:

Determine which patient conditions are consistent with the cues?
Select cues that support or contradict a particular condition?
Determine why a particular cue or set of cues is of concern?
Determine which missing information would help to establish the significance of a cue or cues?

Prioritize Hypotheses

In this step, students must evaluate and rank hypotheses according to their priority, including urgency, likelihood, risk, difficulty, and time. Ask yourself, does the test taker need to:

Determine which explanations are most or least likely?
Select which possible explanations are the most serious or urgent?

Generate Solutions

When generating solutions, the student must identify the expected outcome and use the hypotheses to select a set of interventions to help meet the outcome. Ask yourself, does the test taker need to:

Determine desirable outcomes for the patient?
Select interventions to achieve the outcomes?
Determine what should be avoided?

Take Action

In this step, the student implements the chosen solutions that address the highest patient priorities. Ask yourself, does the test taker need to:

Decide which intervention or combination of interventions is most appropriate?
Determine how the intervention(s) will be accomplished, such as performing a skill, administering a medication, teaching the patient or family, documenting, etc.?

Evaluate Outcomes

Here the student observes the patient’s outcome and compares it to the expected outcomes. Ask yourself, does the test taker need to:
Determine which signs indicate that the patient is improving, declining, or remaining unchanged?
Decide if the interventions have been effective?
Choose an intervention that would have been more effective than the one done?

Revising Exams for Clinical Judgment

If, after completing your exam blueprint, you realize that you are primarily testing on only one or two components of the NCJMM Level 3 and neglecting the others, or if you realize that your questions are more knowledge-based and do not fit into the NCJMM at all, it is time to start revising your questions or writing new ones.

To get into the right frame of mind, think of each question (or a series of several questions) like a miniature case study. Rather than asking students to memorize facts, we want them to demonstrate how they can care for patients and make clinical decisions that are appropriate and safe.

Here is an example of one way to elevate a knowledge-based question to a clinical judgment question.

What is the onset of insulin regular?

2 to 15 minutes
15 to 30 minutes
30 minutes to 1 hour
1 to 2 hours

Using the same set of questions that were used to evaluate your exam questions, we can see that this item does not fit into any steps of the NCJMM. Rather, it tests the student’s ability to memorize information. To transform this question, consider integrating Layers 3 (NCJMM steps) and 4 (individual and environmental factors) into the question.

The nurse is caring for a 73-year-old male with a history of type 2 diabetes and peptic ulcer disease who has been admitted to the medical-surgical unit for treatment for cellulitis on his right calf that occurred after sustaining a 2-inch laceration while doing work in his garden. At 0800, the patient uses the call button to request another dose of pain medication. The nurse checks the medication administration record (below). Which is the priority action for the nurse?

Medication order	Administration record
Insulin regular 5 units subcutaneously 30 minutes before each meal	0730 10 units administered LLQ
Famotidine 20 mg PO once every day	Next dose due at 0900
Cefazolin 2 grams IV q 8 hours	Next dose due at 0900
Acetaminophen 1000 mg PO Q 6 hours PRN for pain	0422 administered for a pain rating 3/10

Prepare to administer the ordered famotidine and cefazolin
Call the provider to request additional pain medication
Assess the patient’s level of consciousness and for dizziness
Check the patency of the IV

In this transformed item, the test taker must use clinical judgment to determine the correct answer. They must recognize important cues within the stem, analyze the cues by connecting the medications to the patient’s medical history, and select the appropriate next step.

Where to Start

The most important place to begin is in the classroom by providing plenty of opportunities for students to develop and practice their clinical judgment skills. Then for the exams, start small by revising just a few questions at a time. In time, your classroom and exams will transform to better align with the NCJMM.

About the Author

Liz Lucas has been an RN since 2008 and has an Ed.D. with Emphasis in Nursing and Health Professions Education. Liz’s clinical background is in oncology, and she later transitioned into nursing academia where she taught in a pre-licensure nursing program for several years. Liz feels passionate about building a strong nursing workforce through increasing education accessibility and believes in the role of technology in that pursuit. At Osmosis, Liz manages the nursing assessment and scripting teams. Liz currently lives near Baltimore, MD with her husband, two sons, and dog.

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