Why You Need to Worry About the New NCLEX

The Next Generation NCLEX (NGN) project has been going on for quite a while now. It's sought to determine if its questions really test what new nurses need to know when they enter their practice for the first time. Currently, only 20% of employers felt that new nurses are empowered with the knowledge to make critical clinical decisions- and that can account for some of the high error rate of new nurses (50% in the first year of practice!), low confidence to advocate for patients, and high turnover in hospital staffing.

In an effort to do better, NCLEX is considering some drastic changes, and I don't mean to be inflammatory here, but you should be afraid. You should be very afraid.

As technology has improved and the price of it has fallen, the NCSBN has considered using it to greatly enhance questions. And I don't just mean new drag-and-drop scenarios. I'm talking playing through clinical scenarios like a video game where you need to make the right choices. Or else you don't get to become a nurse.

Above is Dr. Phil Dickinson, PhD, RN, and Chief Officer of Operations & Examinations of NCSBN. (If you click the image above, it'll take you right to the new NGN Talks from which this post's screenshots are from.)

Good ol' Phil walked us through not only the new question types listed above- he also took us through quite a lot of example questions that future nurse graduates will be asked in the duration of their NCLEX exam.

Let's look at three of those sample questions.

1. Cloze Item

A cloze question is one in which there are embedded answers or drag-and-drop answers. In the above question (apologies for the screenshot quality- the video didn't offer anything better), it reads, "Read the following case study- then refer to the case study to answer the question.

The nurse is preparing to administer scheduled medications to a 57 year old male client for whom the nurse has the following data."

You now have to know, as a graduate nurse, what the heck is normal, not only for a few things, but with a whole lot of information, not all of which is even relevant to the question. You have to know the following just to answer this SINGLE question: the normal for post-knee surgery, all vital signs, medication allergies that might conflict with what's ordered, something in the medical history that might contradict the new medications, all laboratory result ranges, the correct diet for someone post knee surgery, what medications are okay pre x-ray, all typical medication doses for that question...

And then there's a bit more you have to know. Let's look at the right column in this question:

You now have to do two things: the medications that will conflict with some tiny piece of the avalanche of data with which you've been bombarded as well as why you have chosen your answer. Guys, they're making you provide your question rationale or you get this question WRONG.

2. Extended Multiple Response (EMR) Items

In the above question, you once more have to refer to a case study with a giant list of information that you better know front and back, because you have zero clues there. Then, based on this information, you must select what findings 24 hours later are unrelated to the diagnosis, signs of potential improvement, and signs of a potentially worsening condition. So besides the usual abnormals, you have to know what's unrelated, what's normal for 24 hours later, and what is evidence of things improving or worsening.

I seriously wouldn't expect a newly licensed nurse to know these things until he or she is two years into his practice, at least with the quality of graduate nurse produced by schools at this moment.  Holy moly...

3. Rich Media

This is a point-and-click scenario. "Which finding in the diagram should the nurse follow up? Click on the finding." I see a couple things. Look at the description above: the client who is scheduled for right total hip replacement in 2.5 hours. Well, she shouldn't be eating that sandwich, nor drinking the liquids. But what the heck is going on with her blood pressure reading?

Could you answer that question correctly? I'm not sure many new graduates could.

Summary of Findings

What We Don't Know Yet:

• We don't know how these new items will be scored. I highly doubt that any question item that features "extended multiple response" will be an all or nothing scenario. Partial credit may become a possible scenario. Even Phil (lecturer above) stated that scoring these questions may differ from the current guidelines.
• We don't know when these new question items will come into play. Per the NCSBN's web site, there is no timeline for the above changes. I am of the opinion that the next NCLEX-RN update (2019) and the NCLEX-PN update (2020) will be far too soon to implement these changes. I estimate it will take anywhere from 5-10 years to include items like the above on the NCLEX exam.
• We don't know which of the proposed question items above will be scrapped and which will make the cut. Regardless, you can be sure that technology will be implemented that should scare the pants off any student who plans to become a nurse toward the end of the 2020s. Imagine a virtual reality headset where you are actually in the scenario and are being judged on your evaluation of the data presented, as well as the nursing actions you take. Scary!

Conclusions:

I believe that the new test items will more accurately prepare a graduate nurse to enter the nursing field with confidence, improved knowledge, and the ability to make critical decisions. I also believe the NCLEX will become substantially more difficult to pass, and the Pass Rate will initially fall below 50%, no matter what nursing schools do. This issue stems from the fact that nursing schools are notoriously slow to change their curriculum, and I guarantee you that they will not be ready for these changes when they are implemented in the exam; nursing schools are just not used to prepping students to become the high level of critical thinkers that the new question items require.

NCLEX Simplified, on the other hand, will be ready to prep you for whatever the future NCLEX entails. I don't care if they make you take blood pressures on robotic SIM men and women and perform CPR by yourself; we'll ensure you're prepped to take the new NCLEX with confidence!

What are your thoughts on these new question items? Let us know what you think.