Next Generation NCLEX: What do I need to know?
The purpose of this activity is to explore the upcoming changes to the National Council Licensure Examination (NCLEX) for LPNs and RNs and the implications of these changes for nurse educators and nursing programs.
Upon completion of this module, the learner should be able to:
- Identify the purpose and current standards of the NCLEX for LPNs and RNs.
- Determine the upcoming changes that will occur with Next Generation NCLEX (NGN).
- Consider the implications for nursing programs and nurse educators with NGN.
- Explore new types of test items that will be used on the NGN.
Since 1994, students who successfully complete an approved nursing program in the US are eligible to sit for the national licensing examination to become a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). The test is developed by the National Council of State Boards of Nursing (NCSBN) and is designed to test for minimum knowledge, skills, and abilities of the nurse entering practice in order to deliver safe and effective care to the patient (NCSBN, 2019a).
Current NCLEX Testing Standards
The LPN and RN must successfully pass the computerized adaptive test (CAT) that is administered at a Pearson Professional Testing Center in order to practice and receive a nursing license within their state. Testing centers are located within each state across the US. CAT testing selects questions based on answers given to previous questions, and individuals are scored by their ability to critically think through the questions as they consider hypothetical decisions that are made during nursing care. Changes and updates are frequently made to the NCLEX based on surveys that are sent to recently licensed nurses about nursing activities that appear on the NCLEX as well as analyzing current trends and practices within nursing. The surveys and analyses occur every three years, and changes are made accordingly (NCSBN, 2019a).
The NCLEX-RN is the version of the test used to license RNs, and is based on the following four categories of client needs (see Figure 1):
1. Safe and effective care environment
- Management of care
- Safety and infection control
2. Health promotion and maintenance
3. Psychosocial integrity
4. Physiological integrity
- Basic care and comfort
- Pharmacological and parenteral therapies
- Reduction of risk potential
- Physiological adaptation(NCSBN, 2019a)
As of 2019, the test ranges from 75-265 examination items, and 15 are considered "pretest" items that are not scored. These items are pilot questions that are administered for reliability and validity data as future exam items. The total time allowed for the examination is six hours, regardless of the number of questions given. The time allotted includes all breaks, tutorials for directions on the exam, sample items, and exam completion. The exact time of the test for each individual is based on how they answer the questions and their pattern of correct and incorrect responses. Typically, one to two minutes are spent on each exam item. Each individual is given an exam based on the test plan outlined on the NCSBN's website. The opportunity to demonstrate competency and ability is afforded to each individual through the exam. The passing standard is re-evaluated every three years, along with the exam items. The criterion is based on the minimum level that can be set for nurses to deliver safe and effective care upon entry to practice. This determination is done through surveys sent out to educators and employers, the historical record of the passing standards with candidate performance related to the standards, and oversight by psychometricians to determine the reliability of the standard-setting practice by the NCSBN (NCSBN, 2019a).
Scoring with CAT is different from traditional examinations that apply the same number of exam items to each individual. This type of testing can produce exam results that are more precise and efficient since they are targeted to the individual candidate's capability. Traditional tests ask high-ability test takers to answer all questions, even the ones that are too simple for them; low-ability students are asked to guess at questions that are too advanced for them. The traditional type of testing is not as reliable under these circumstances. The computer determines the ability of the candidate in relation to the passing standard. With each question answered, the computer re-estimates their ability, and with each question that is answered correctly, the estimation of the individual's ability is more precise. Each item that is delivered to the individual is based on three criteria:
- Item content that matches the overall test plan percentages.
- Item is chosen that will match the candidate’s ability.
- Items are excluded that have been given previously with repeat candidates (NCSBN, 2019a).
Passing and failing is determined through one of three scenarios:
- The 95% Confidence Interval Rule, which states that the computer will shut off if it is 95% certain the candidate is clearly above or below the passing standard.
- The maximum length of the exam which states that the computer has administered the maximum number of test items. The 95% Confidence Interval Rule will be disregarded, and only the final ability estimate will apply. If their final ability estimate is above the passing standard, they will pass; if their final ability estimate is below the passing standard, they will fail.
- The run-out-of-time rule (ROOT) states that if an individual runs out of time before they get the number of items required for the computer to determine with 95% certainty whether they have passed or failed, an alternative criterion is applied. If they have not answered the minimum number of required items by the time they run out of time, they fail. If they have answered the correct number of items during the time, then only the last 60 ability questions are used to determine passing or failing (NCSBN, 2019a).
A majority of items on the NCLEX are multiple-choice, priority type questions. There are also multiple response, fill-in-the-blank, calculations, hot spots, ordered response, audio and graphics, and exhibit questions. Any type of exam item may include multi-media, charts, tables, graphics, or audio. There is no partial credit for any type of test question, including the select all that apply (multiple response) questions. The individual must answer each question with complete accuracy regardless of the exam item style to receive credit (NCSBN, 2019a).
The NCLEX examination is meticulous with security and confidentiality and requires that a student who leaves the testing center must maintain those standards. Disclosure of exam items before, during, or after the examination can lead to a denial or loss of licensure, civil liability, or disciplinary actions by the licensing agency. The current test plan will remain in use through March 31, 2022. As the NGN is not expected before March of 2023, an updated short-term test plan may be implemented for 2022-2023, but at this time, the NCSBN has not specified how it will handle this one-year gap between test plans (NCSBN, 2019a).
The NCLEX PN is the licensure exam designed for LPNs. It went into effect in April 2017 and will apply through March 31, 2020, with updates going into effect in April 2020 (See Figure 2 below). The 2020 updates will run through March 31, 2023, when the NGN will be implemented. The test is based on four categories of client needs:
1.Safe and effective care environment
- Coordinated care
- Safety and infection control
2. Health promotion and maintenance
3. Psychosocial integrity
4. Physiological integrity
- Basic care and comfort
- Pharmacological therapies
- Reduction of risk potential
- Physiological adaptation (NCSBN, 2019a)
These categories are distributed as noted in Figure 2:
Distribution of Content for the NCLEX-PN Test Plan
As with the NCLEX-RN examination, the test is delivered via CAT. There are 85-205 exam items on each test, with 25 of these items being pretest items that are not scored. The total time available for this exam is five hours and includes the time for taking the examination, breaks, tutorials, and sample items. The total time required will be based on the individual's performance, as in the RN exam. Passing and failing is based on the same criteria as the NCLEX-RN examination previously discussed in this section (NCSBN, 2020b).
Next Generation NCLEX
In 2009, the NCSBN held conversations with professionals in clinical practice and nursing experts, determining that the current level of decision-making in nursing led to a large number of practice errors by entry-level nurses. Studies show that as many as 65% of entry-level nurse errors are related to poor clinical decision making and that only 20% of employers of new nurses are satisfied with their decision-making capabilities. From 2012-2014, the NCSBN collaborated on two studies looking at nursing practice and the entry-level nurse. These studies established the need for clinical judgment as one of the top five skills required to enter nursing practice. Two other high-priority skills were problem solving and critical thinking, which are both vital to clinical judgment. The other two required skills for entry to practice were identified as active listening and professional communication. The RN Nursing Knowledge Survey from 2017 offered more evidence on the need for clinical judgment. Newly licensed RNs, RN supervisors, and RN educators unanimously agreed on the importance of clinical judgment. Experts in the LPN field had a further agreement on the need for clinical judgment. Based on the findings of the studies and experts, the NCSBN moved forward with a Next Generation NCLEX Project. The NGN has a focus on protecting the public and achieving optimum outcomes for the client, the nurse, and ultimately health care institutions. This exam will ask questions in a different way and help nurses to think critically while providing care or making clinical decisions. Case studies will be used on this exam, and a focus on interactions between the client and the nurse, client outcomes, and expected outcomes will be considered (NCSBN, 2019a).
Many steps are being taken by the NCSBN to ensure the efficacy and reliability of the exam in the new structure. Starting in July 2017, the NCSBN presented a Special Research Section (SRS) as part of the NCLEX-RN exam. Individuals who were selected were given 30 minutes to complete the SRS after their standard NCLEX-RN exam with no impact on their NCLEX score. At the end of the standard NCLEX-RN exam, a candidate is given an introductory screen that indicates the beginning of the SRS. The section is numbered in accordance with the previously completed exam so that if an individual received 75 questions on their initial exam, the SRS would begin with question number 76(NCSBN, n.d.).
Figure 3 is a visual of the steps the NCSBN is taking to ensure the NGN exam is reliable and effective.
The launch of this exam is estimated to occur no earlier than 2023 for the NCLEX-RN or the NCLEX-PN. This exam will be developed using scientific standards by the NCSBN. The validity of the exam will include:
- The extent to which clinical judgment can be measured.
- Numerous writing panels made up of nursing faculty to write items aligned with the clinical judgment measurement model.
- Committees of nursing experts made up of faculty, clinical educators, and clinicians that will review the measurement and content for accuracy.
- Ensure that items are statistically and clinically sound based on contemporary practice (NCSBN, n.d.).
Clinical judgment in relation to NGN is defined based on an assessment framework developed by the NCSBN after extensive review of the nursing literature, decision theory, and testing. This framework is referred to as the NCSBN Clinical Judgment Measurement Model (CJMM). It is for testing only and should not serve as a replacement for evidence-based practice or theories. The CJMM provides a framework for measuring the competency of nurse licensure candidates with respect to clinical judgment and decision-making. Further, the NCSBN has made it clear that they do not intend for the CJMM to replace the nursing process (NP) and does not compete with the NP or other pedagogical models around the teaching of clinical judgment. The model can offer educators a tool to evaluate the clinical judgment of a student in the classroom or clinical environment. Most exam items the NCSBN is currently developing are unfolding case studies that are currently in use in nursing programs. Nursing programs that are currently teaching clinical judgment in an evidence-based curriculum are effectively preparing students for the new exam components (NCSBN, n.d.).
Implications for Nurse Educators
With the implementation of the NGN expected in 2023, students entering a two-year program in the spring of 2021 will likely take the new-style of NCLEX. What does this mean for nursing programs and their delivery of curriculum and evaluation? As with the old NCLEX, educators cannot teach to a test. Rather, the curriculum should be based on evidence and current needs within the health care system, as well as partners and stakeholders of the nursing program. The NCSBN offers a wealth of information on its website related to the current NCLEX-RN and NCLEX-PN test plan as well as information on the NGN development and implementation. Students should practice NCLEX-style questions throughout their program and develop familiarity with alternate format question styles in addition to the basic multiple-choice, priority question. Faculty should be prepared for questions from students related to the NCLEX and where possible, integrate NCLEX-style questions into the evaluation process of the program. Current students graduating from nursing programs and taking the NCLEX-RN may be asked to participate in the SRS as previously discussed. While this participation does not affect their score on the NCLEX, it gives the NCSBN valuable data in relation to performance on current exams and the new style of exam items. Educators will not receive reports on their individual students’ performance on the SRS; however, ongoing updates on the NCSBN website will be made available to inform nursing stakeholders. Since all aspects of the NCLEX are confidential, test-takers are not allowed to share their experience with others (NCSBN, n.d.).
NGN Test Item Types
A common question about the NGN is “what will the test items look like?” Based on information located on the NCSBN website, the following test item types will be part of the NGN exam:
- Extended multiple response.
- Extended drag and drop.
- Cloze (drop-down).
- Enhanced hot spots (highlighting).
- Matrix/grid (NCSBN, n.d.).
The extended multiple response question will allow the individual to select one or more answer options at a time. While similar to the current multiple response questions, these will have more options and provide partial credit scoring (as previously mentioned, current multiple response questions require 100% accuracy for credit). The extended drag and drop will allow individuals to move or place responses into answer spaces. This is similar to the current ordered response questions, but not all items will be used or required to answer the question correctly. In other words, there will be more options than answer spaces. The cloze question allows candidates to select from a drop-down menu and choose the correct answer. These menus can be used to complete phrases within a sentence, table, or chart. Enhanced hot spots or highlighting allows the individual to select their answer by highlighting it. This type of question may require that the individual read a chart, lab value, or another part of a medical record and then select the words or phrases that answer the exam item. Finally, the matrix/grid items allow the individual to choose one or more answer options for each row or column. This can be used with clinical scenarios in measuring multiple aspects within a clinical item (NCSBN, n.d.).
The NCSBN is currently developing test items internally and will share the information with test preparation and publishing companies at a later date, once the research has been validated and the final test design has been determined. While the final implementation date and all aspects of the exam are still to be determined, the NCSBN has offered advice to educators to incorporate the CJMM into their curriculum immediately, which is displayed in Figure 4 below.
Layers 3 and 4 of the CJMM delineate the cognitive decision-making processes for layer 2. According to the client response in layer 2, the nurse then moves through layers 3 and 4 again. Layer 3 is the area where testing can take place to determine the education of entry-level nurses and how they develop clinical judgment over a period of time. The six steps within layer 3 make up a repetitious process the student can improve over time with nursing experience and clinical exposure. Layer 4 creates a realistic client scenario and the two combined determine expected behaviors of a clinical case or scenario. The CJMM is appropriate for use in the lab setting, clinical setting, and on a standard written or computer examination. See Figure 5 and 6 below for sample action model templates from the NCSBN to help faculty begin to assess clinical judgment. They “incorporate specific concepts of the CJMM…in order to close the gap between what is measured on the exam and what is taught in clinical education” (NCSBN, 2019b, p. 1).
Further training by the NCSBN for faculty will occur in the near future, once the item formats are finalized. Additionally, the NCBSN encourages nursing faculty to volunteer as item writers. The application is found on their website, along with on-demand webinars related to the item-writing process for both the current NCLEX test plan and the NGN item writing panels (NCSBN, 2020a). Webinar series are available on the NCSBN website for further information related to the NGN and how it will impact faculty and students in the future (NCSBN, 2018).
National Council of State Boards of Nursing. (n.d.). Next generation NCLEX project. Retrieved on January 8, 2020, from https://www.ncsbn.org/next-generation-nclex.htm
National Council of State Boards of Nursing. (2018). NCLEX examinations webinar series: Next generation NCLEX (NGN) project. https://www.ncsbn.org/13064.htm
National Council of State Boards of Nursing. (2019a). NCLEX-RN examination: Test plan for the national council examination for registered nurses. https://www.ncsbn.org/2019_RN_TestPlan-English.pdf
National Council of State Boards of Nursing. (2019b). Next Generation NCLEX news: Clinical judgment measurement model and action model. https://www.ncsbn.org/NGN_Spring19_ENG_29Aug2019.pdf
National Council of State Boards of Nursing. (2020a). Exam volunteer opportunities. https://www.ncsbn.org/exam-volunteer-opportunities.htm
National Council of State Boards of Nursing. (2020b). NCLEX-PN-examination: Test plan for the National Council Licensure Examination for practical nurses. https://www.ncsbn.org/2020_NCLEXPN_TESTPLAN.pdf