As nursing practice becomes more complex, the NCLEX® is following suit. The innovative new item types being introduced as part of the Next Generation transition will bring the most significant change to nursing licensure testing since computerized adaptive testing. Every 3 years, educators anticipate a fleeting dip in student performance following the introduction of each new test plan. However, candidate performance has not yet recovered following the most recent test plan update in 2019. In fact, first-time pass rates of US-educated graduates have steadily declined for three consecutive years now. In the face of the heightened NCLEX® challenges and upcoming Next Generation transition, we must re-examine how we coach our students to approach questions.
While nursing’s conventional test strategies (such as Maslow’s or “assess first”) can be useful, the practice environment and its licensing exam are now asking much more of graduates. Fortunately, the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Model (CJM) has answered with a cognitive model for clinical judgment:
- Form Hypotheses
- Refine Hypotheses
Applying the CJM as a testing strategy can facilitate students’ application of clinical judgment in test item scenarios. This model incorporates several familiar bedrocks of testing strategy, yet the streamlined, three-step process will enable students to keep salient steps in mind without becoming overwhelmed. Practicing this approach now will benefit students who will later be tested under the Next Generation NCLEX®, which walks students through the same cognitive steps in an unfolding manner that is summarized in the acronym FREE: Form Hypotheses, Refine Hypotheses, Evaluate Outcomes, Explanation Review.
1. Form Hypotheses
The first step is to read the stem carefully—before looking at the options—and visualize the clinical scenario. You can also picture each client scenario using every descriptor provided. At face value, a client with COPD who has “an oxygen saturation of 90% while eating breakfast,” may sound scary and set off students’ alarm bells for issues of airway or breathing. However, visualizing the same scenario in detail helps reproduce the clinical picture the item writers intended to convey.
The hypothesis is based on:
- What is currently happening with the client(s);
- What needs to happen; and
- In what time frame
Is the stem asking what you would do next, first, or as a priority? Once you decide what needs to happen with the client, you may read the options.
2. Refine Hypotheses
The second step involves reviewing the options and eliminating any known incorrect answers.
- If something registers as a known safety risk, you should immediately eliminate this option and focus only on those remaining.
- If a safety risk would satisfy the hypothesis for a negatively worded stem, instead highlight this option before examining the others.
- Then consider which options satisfy the hypothesis.
Maybe the most important intervention you envisioned for a client with acute hemorrhage is to be taken to the operating room immediately. However, you now see that the only option available that might satisfy this hypothesis is to page the healthcare provider. Refer to the time frame defined in the prior step, which asked what to do first. This decreases the strength of such a distractor that would delay care.
3. Evaluate Outcomes
For each remaining option, what will happen? In the case of a client hemorrhaging from an open wound:
- If you choose to page the healthcare provider, what happens next? Will you stand there and watch the client bleed while waiting for the provider to arrive?
- Maybe the item includes an option to “take the client’s blood pressure.” This incorrect option is attractive to students according to the “assess first” prioritization principle. However, visualizing this option’s outcome should reduce its attractiveness as a distractor: should you stand there waiting for the blood pressure cuff to cycle while the client continues to bleed? Additionally, will taking the client’s blood pressure change anything? No, the client likely requires emergent surgery regardless of what the blood pressure is.
- Finally, what about the option to “place pressure on the site and call for help”?
This step is crucial to navigate away from strong distractors and second-guessing options that do not follow the ABC, Maslow’s, or “assess first” conventions. You can now select the best answer.
4. Explanation Review
Maybe most importantly, you should review the explanation regardless of whether you answered the question correctly or incorrectly. You’re now primed and ready to receive new information that will translate to future scenarios and test questions you encounter. This exercise has effectively taken you from the knowledge level (“clients with hemorrhage require emergent surgery”) to the application level (“clients with hemorrhage need surgery, and I should do whatever I can to stop the bleeding now, such as hold pressure or apply a tourniquet.”)
Explanations should break down precisely why each option is correct or incorrect, and incorrect options should contain strong teaching points. This enables students to translate their new understanding to as many other questions as possible. In our example scenario, you have not only learned to apply hemorrhage management but also have a better sense of when something is too urgent to delay care or when “assessing first” may not be useful. This single practice question will help you on numerous others.
If this process seems tedious at first, keep in mind that you’ll refine this approach over thousands of questions practiced. Over many weeks, this process should become second nature. We want our students to be so comfortable in their practice that they report “the NCLEX felt like just another practice test.”
The earlier you begin practicing in this way, the more you’ll be able to space out your practice sessions. This regular, repeated practice is called “the spacing effect,” and produces significantly better performance than if the same number of questions were reviewed over a shorter period of weeks or months. This is why question bank review using an organized framework should be introduced as early as the first semester of pre-licensure programs. Consistent test practice in this structured fashion will help facilitate the transition to Next Generation-style testing for students and educators alike, while enhancing clinical reasoning, increasing test confidence, and guiding students through specific, deliberate practice.