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Feb 14, 2021, 11:33 AM
<13.5-min. read> Review important skills related to clinical judgment, activities that indicate whether a nurse possesses those skills, and 5 new item types that will be used to assess this crucial ability.


Dr. Sheryl SommerWhen she’s not talking to nurse educators about NGN, she’s talking to the NCSBN. Those conversations are a regular occurrence for Sheryl Sommer, PhD, RN, CNE, ATI Vice President and Chief Nursing Officer. Listening to her colleagues’ questions and attending industry-wide conference presentations often lead to one-one-on chats with individuals at the NCSBN, including Phil Dickison, PhD, RN, Chief Officer, Operations & Examinations at NCSBN.

In these discussions, Dr. Sommer delves into misconceptions she regularly encounters from within the nursing profession and discerns them from the facts. Then, she uses the information to develop actionable ideas — in conjunction with her ATI nurse educator colleagues — to deliver video updates for nurse educators working to prepare for the new version of NCLEX.

This video* provides some details that were new at the time it was presented. It then delves into evergreen information that you'll find beneficial as you prepare for the launch of the exam.

Jump ahead to the sections of most interest to you in the video or in the transcript below:

  1. A comparison of the Clinical Judgment Measurement Model to other mental models [00:01:49] 
  2. A survey of skills related to clinical judgment and activities that indicate a nursing student or novice nurse possesses those skills [00:02:48]
  3. Specific activities you can use when helping students develop skills related to the stages of the Clinical Judgment Measurement Model [00:03:34]
  4. Examples of the 5 new item types that NGN plans to include on the NGN [00:11:15]

Following is a transcript of Dr. Sommer’s video:

ANNOUNCER KATIE GLASS [00:00:00] Welcome to the update on NCSBN's Next Generation NCLEX project. ATI is pleased to share this latest information on this important topic with you. It is my pleasure to introduce Dr. Sheryl Sommer, vice president and chief nursing officer at ATI. Dr. Sommer is an experienced visionary leader in nursing education. She has been a reviewer for several nursing journals and author of numerous publications. Her passion for nursing education is evident in her work, guiding development of products to promote the development of clinical judgment, helping faculty develop skills in areas such as clinical judgment, curriculum development, and student evaluation. Please join Dr. Sommer as she shares this important information about the Next Generation NCLEX.

DR. SHERYL SOMMER: [00:00:52] Thank you, Katie, and welcome to the Next Generation NCLEX update. I'm excited to share some new information with you today. As we start, I want to just make sure that there are a couple of things that just remain to the front of your mind, and that begins with the launch of the Next Generation NCLEX.

[00:01:12] They are still anticipating a launch not before 2023. And NCSBN, on occasion, has mentioned that it could even happen in 2024. So, we will just need to wait, allow them to continue their development, develop their scoring algorithm and the infrastructure they need to actually deliver these new items and score them before they'll be able to really give us an actual launch date.

[00:01:40] They do also plan to launch the Next Generation NCLEX for both RNs and PNs simultaneously. 

[00:01:49] This is a copy of the Clinical Judgment Measurement Model. The stages included are: 

  • recognize cues
  • analyze cues
  • prioritize hypotheses
  • generate solutions
  • take actions
  • and evaluate outcomes. 

We're going to focus on comparing the model and all of these stages to the Nursing Process during this presentation. 

[00:02:12] The top of the slide has the Clinical Judgment Measurement Model with the Nursing Process below it. As you can see, assessment is aligned with recognize cues. Analysis is aligned with analyze cues. And planning, in the Nursing Process, is actually aligned with prioritize hypotheses and also generate solutions. Implementation, for the Nursing Process, is aligned with take actions, and evaluation is aligned with evaluate outcomes. 

[00:02:48] At ATI, we conducted a survey last year, and the survey was developed to identify important skills related to clinical judgment and the activities that nurses perform to actually incorporate clinical judgment into the care of clients. What we did was we looked at all of those cognitive domains — the six we just mentioned — that are in the NCSBN Clinical Judgment Measurement Model. We assessed all of them, and we asked a group of educators and also a group of nurse educators from the hospitals to tell us what the nursing activities were that were related with each of those stages.

[00:03:34] From the information that we found, we're going to be including that in the following slides to be able to, hopefully, help you better understand some specific activities that you might use when helping students develop skills around each of those strategies or those stages of their Clinical Judgment Measurement Model. 

[00:03:53] The first stage is recognize cues, also assessment in the Nursing Process. It's defined as filtering information from different sources. It could be things like signs, symptoms, a client's medical history — all of those things provide types of information that the nurse needs to be able to filter. 

[00:04:20] When we think about the nursing actions that are related to recognize cues and, again, these came from the ATI research that we did, we found that this particular stage involves the following actions: 

  • use knowledge, experience and evidence to assess clients
  • collect relevant subjective and objective client data
  • and also identify subtle and apparent changes in the client condition, as well as related factors. 

[00:04:55] The next stage is analyze cues, which is analysis in the Nursing Process. It's defined as linking recognized cues to client's clinical presentation and also establishing probable client needs, concerns, and problems. So, in this one, we're trying to identify what is that particular thing that's going on with the client — that problem that we, as the nurse, need to address. Nursing actions related to this particular stage include being able to compare client findings to evidence-based resources and standards of care; documenting and communicating expected and unexpected patterns, trends, changes in clinical findings. It's not enough to just identify that something is either expected or unexpected. But we also need to be able to identify if there are trends, even if a particular finding, such as a blood pressure, is still within normal limits. But if you're seeing a trend, over the last few hours or of the last few months, perhaps, then we know that there might be a problem that needs to be addressed. 

[00:06:13] The third action is recognize when to seek guidance from more experienced colleagues. 

[00:06:20] The next is to differentiate signs and symptoms of a client's condition that presents similarly to different health problems. This was identified very specifically by the nurse educators that are in practice, because — oftentimes — they're finding new grads, particularly, who are caring for a client that's exhibiting a certain kind of symptom, and they're automatically linking it to — perhaps — their current diagnosis or something else. But they're not recognizing that it's actually related to a different health problem, and if we don't understand the actual health problem or condition that's causing these symptoms, we may not be addressing it appropriately. 

[00:07:06] We also find:

  • analyze unexpected findings in health data
  • anticipate illness or injury and wellness progression
  • identify client problems related to health alterations. 

[00:07:26] The next stage is called prioritize hypotheses, or planning in the Nursing Process. This is defined as evaluating and ranking hypotheses according to priority. And we may be looking at things like the urgency, likelihood of something happening, the risk of a potential problem developing, perhaps the difficulties a client is experiencing, or something related to the time.
[00:07:53] When you think about what the nurse needs to do, in relationship to this particular part of the clinical judgment process, they need to do things like organizing the client assessment information and data according to changes, patterns, and trends. They need to be able to use standards of care and empirical frameworks for priority setting. They need to be able to establish and prioritize hypotheses based upon the analysis of information and factors. 

[00:08:28] The next stage is to generate solutions, or planning in the Nursing Process. With this particular one, we need to identify expected outcomes, use hypotheses to define a set of interventions for the expected outcome to be achieved. 

[00:08:49] When we think about nursing actions that need to happen, those would include identifying the optimal client outcomes based on information and factors; identifying evidence-based nursing actions to effectively address the underlying cause of a client's health problem; prioritize the plan of care to achieve optimal client outcomes; prioritize nursing care when the care for multiple clients is something that they're needing to do; reprioritize nursing actions as the client's condition changes; and modify a plan of care to assure achievement of optimal client outcomes when indicated. 

[00:09:31] The next stage is to take action, or implementation in the Nursing Process. It's defined as implementing the solutions that address the highest priorities. Sometimes, no action is really required and, honestly, that is an action in and of itself, because it is still a decision whether you're going to perform an action or you're not going to. 

[00:09:55] Nursing actions related to this stage include: promptly and accurately performing nursing actions based on prioritized client problems; incorporating client preferences and needs when performing nursing actions; providing education to the client and or care partner regarding their health condition and care management; also participating in coordination of care with the client and the entire healthcare team. 

[00:10:22] The last stage is to evaluate outcomes, or evaluation in the Nursing Process. That is defined as comparing observed outcomes against expected outcomes. 

[00:10:36] In doing this, the nurse needs to reassess client condition to determine achievement of expected outcomes. They need to evaluate the efficacy of nursing actions to determine if a client outcome was met or not met. They need to modify client outcomes and/or nursing actions based on the client's response and clinical findings when indicated. And, finally, they need to update and revise the plan of care as needed. 

[00:11:15] NCSBN has said that they have determined that these are the item types they are moving forward with in development of the Next Generation NCLEX. So, I'd like to provide you with an example of each of them, so that you have an idea of what it is that they're actually moving forward with. 

[00:11:36] The Extended Multiple Response item will provide candidates with a scenario followed by a question that may have one or more correct options. 

[00:11:47] In this particular example, it says, "Use the following client data to answer the question. The nurse is assessing a client who reports having frequent diarrhea for three days." Then the candidate is given the question that says, "Which of the following actions should the nurse take?" And they are to select all that apply. Often, I get a question that says, "How many responses would be correct in a Multiple Select or, in this case, the Multiple Extended Response item?" And the response from NCSBN is always, "One or more." When I think about that, statistically, I would probably shy away from presenting an item where all of the responses are correct, because that might seem to be a very obvious option for a student who doesn't really know the answer: clicking all of them, hoping that they would get the majority of them correct. So, it's going to be "one or more," and they don't really give it any more information than that. 

[00:13:02] Cloze is another item type. It requires candidates to select information from a dropdown list in response to questions. In this particular example, a candidate would read, "Read the following case study and then refer to the case study to answer the question. The nurse is preparing to administer medications to a client who is two hours post-op following a total knee replacement. The nurse has the following data ..." And you can see things -- everything from a diagnosis, current vital signs, allergies, medical history, lab tests, diet. There could be other things, as well. But that's what's included in this example. The question says, "Which three medications require clarification prior to administration. Complete the following sentences by choosing from the dropdown lists. Do not use the same medication selection more than once." So they would read, "The nurse should not administer..." Click on the select dropdown to the right, and it would give a list of medications. They would click one, and then they would finish "Because" and then click that select dropdown arrow and identify the reason that it would not be administered. 

[00:14:17] Enhanced Hot Spot is another item type that NCSBN is working on. In an enhanced hot spot item, they require candidates to read the scenario and then respond to questions by clicking on information to highlight it. 

[00:14:33] In this particular example, it says, "Use the following scenario and client data to answer the question. A nurse is preparing to administer a dose of clozapine to a client. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold this med?" And the candidate needs to click on both tables to highlight the text that supports the response. So, they would click on something on the left-hand table and then also whatever is appropriate on the right-hand table. There could be more than one particular thing that they want to select to actually have all of the options selected that should be correct. 

[00:15:23] Extended Drag and Drop is another item that NCSBN is working on. An Extended Drag and Drop item provides client information, and the candidate must move information from one area to another in response to the question. This particular one says, "Drag assessment findings that require immediate attention to the boxes on the right." So, they would look at all of the assessment findings list on the left, click on them, and drag them over to the right if they felt that they were some kind of assessment finding that needed immediate attention. 

[00:16:01] Matrix is the last item type that I'll be sharing with you. And, in this item type, they respond to the question by selecting the appropriate responses. In this example, "The nurse is caring for a client admitted to the emergency department following multiple stab wounds to the left leg with active bleeding requiring a fresh dressing every hour. For each potential order below, click to specify whether it is anticipated, nonessential, or contraindicated." So, they would look at all the potential orders, and then they would click on the circle to the right that is the appropriate response that they want to give. 

[00:16:48] ATI is committed to remaining current on information related to the Next Generation NCLEX and supporting you and your students in the development of clinical judgment skills. 

[00:16:59] The NGN updates will continue to be produced. And when there is new information about that NCLEX Next Generation, we will be certain to have another update for you at that time. We encourage you to also follow discussion about the Next Generation NCLEX on the ATI blog site, which is listed on the screen. 

[00:17:22] The above resources were used for development of this update. We encourage you to access the sites for additional information. I want to thank you for joining this particular webinar and learning more about the Next Generation NCLEX updates. Thank you. 

*This video was originally released in February 2020.