Next Generation NCLEX NGN The NCSBN Clinical Judgment

Next Generation NCLEX® (NGN): The NCSBN® Clinical Judgment Measurement Model (NCJMM) Joe Betts, MMIS, Ph. D Director, Measurement & Testing, Examinations

Objectives • Why do we measure clinical judgment (CJ)? • Early CJ research results • NCSBN® response • Literature review • Item bank review • Functional & strategic job/practice analyses • Linkage studies • Resulting NCSBN Clinical Judgment Measurement Model (NCJMM)

Importance of Nursing CJ • From 1990 s to mid-2000 s, growing awareness of importance of CJ • Adverse events could be prevented with good CJ decision-making • Nurses are responsible for a significant proportion of the judgments and decisions made in healthcare • • • e. g. , Brennan et al. , 1991; Hodgetts et al. , 2002; Leape, 2000 e. g. , Thompson et al. , 2004 Newly licensed nurses are required to make increasingly complex decisions about patients • e. g. , Lasater, 2007 • Clinical judgment, clinical reasoning, & critical thinking have been important parts of nursing education • AACN, 2008 • Only 20% of employers were satisfied with the decision-making abilities of new nurses • Berkow, Virkstis, Stewert, & Conway 2008 • Result of growing literature and research • NCSBN® begins to investigate the potential to measure CJ skills at entry-level

NCSBN® Response • Supported a full literature review on nursing clinical decision-making (see Muntean, 2012) • https: //www. ncsbn. org/Clinical_Judgment_Lit_Review_Executive_Sum mary. pdf • Review of NCLEX® items • NCSBN & American Institutes of Research (AIR) collaboration (2013 -2014) • Functional Job Analysis • Strategic Job Analysis • Linkage Workshop • https: //www. ncsbn. org/18 -Strategic-Practice-Analysis. pdf

Literature Review Muntean’s study (2012) focused on • Current, up to 2012, research related to nursing CJ • Main models and frameworks for conceptualizing CJ • Information Processing • Humanistic-Intuitive, e. g. Benner (1984) • Cognitive Continuum, e. g. Hammond (1981), Harbison (2001), & Thompson (1999) • Factors impacting CJ • Individual • Environmental https: //www. ncsbn. org/Clinical_Judgment_Lit_Review_Executive_Summary. pdf

Review of Item Bank • Contains 10 K+ items developed over decades by RN Subject Matter Experts (SMEs) • Random sample of items reviewed to identify what percentage measures CJ • Results: • • All items mapped to the Nursing Process Some items in the bank measured CJ, but Items tended to center around taking actions & evaluating outcomes Items did not represent the full complexity of critical thinking and decision-making skills necessary to measure CJ • No systematic method for writing items was identified • Outcome: • Combined the item writing/review expertise of RN SMEs with expertise of psychometrics and cognitive psychology to develop a method for writing items that measure CJ

Job Analyses Functional & Strategic Analyses

NCSBN® & AIR Collaboration • Functional Analysis • Strategic Analysis • Health care facility site visits • Job analysis survey • Linkage workshop • Rate cross-tab of knowledge and tasks by job duty https: //ncsbn. org/18 -Strategic-Practice-Analysis. pdf

Job Analysis Data Collected

Summary of Research Endeavors • • Two environmental scans: Identify requirements of entry-level nursing and tools used in the workplace • Review recent practice analyses from NCSBN (2009, 2010) • U. S. Department of Labor’s O*NET • Fleishman’s taxonomy of human abilities • Structured interviews with 18 RN clinicians, educators, and regulators Site visits across 4 U. S. regions including 127 RNs across 12 practice care settings • • Conducted observation of daily work, focus groups, and 1: 1 structured interviews Nationally representative job analysis survey (N = 2, 522) • Over 25 practice care settings, all 50 U. S. states and 5 U. S. Territories, & from less than 1 year to 45 years of experience • Provided rating data (frequency, importance, & criticality) on tasks and abilities needed for entry-level practice Four, three-day focus groups comprised of 8 -10 RN SMEs across more than 10 practice care settings to gather evidence on • Duties, tasks, knowledge, skills, and other personal characteristics • Key judgments needed for entry-level and associated consequences of errors • Health care trends Six linkage workshops with • More than 65 RN SMEs across more than 20 practice care settings from 33 U. S. states with 2 to 45 years of experience • Rated the extent to which each knowledge and skill was required for performing each nursing task

Results

Final Job Requirements from Job Analyses • 286 task statements categorized into 11 duty areas • 165 knowledge statements categorized into 24 groups • 65 skills categorized into 10 groups • 75 abilities, e. g. oral comprehension • 54 personal characteristics, e. g. willingness to work in a fast-paced environment • 137 tools & equipment used • 38 emerging health care trends o Example: aging population, cross-state licensing, etc. • 76 key judgments o Example: prioritize daily tasks, when to seek help, etc. • 69 consequences of errors o Example: decline in client health, increased length of stay, etc.

Most Linked Knowledge & Skills to Tasks Knowledge/Skills % of Linked Tasks Knowledge English Language 29. 0% Nursing Process 23. 8% Professional Responsibilities 23. 1% Clinical Judgment 46. 5% Professional Communication 44. 1% Active Listening 38. 5% Problem Solving 34. 3% Critical Thinking 33. 9% Therapeutic Communication 32. 2% Skills

Overlap between Skills

More Results • Of the 11 duty areas that organized the 286 tasks, clinical judgment itself was important for 8 (~75%) • On a scale of 1 to 5, with 5 being most important, all three of the skills had an average importance rating of at least 4. 4 • Over 80% of the nurses responding indicated that all three of these skills are needed for early-career nurses

Conclusions § CJ is an important and necessary skill that entry-level nurses need in order to practice safely and effectively • It underlies much of the actual work done by nurses in delivering safe and effective practice § CJ has not been consistently or directly measured on the NCLEX® § CJ is an integrated process underlying much of nursing practice • Underlying skill necessary for about 46% of vital RN tasks and about 75% of all duty areas § This led to over five years of on-going research to develop the NCJMM • Model that allows for measuring specific elements of the decision-making process in the context of case studies • Item writing and review processes that focus on appropriate situations that entry-level nurses are expected to encounter and need to handle safely

Overview of Research Framework

NCSBN® Clinical Judgement Measurement Model

Thank You Website for general NGN resources: https: //www. ncsbn. org/ngn-resources. htm Includes: • • Muntean’s white paper JATT article on developing clinical judgment items in nursing Strategic practice/job analysis overview Approaches to assessing higher-order cognitive constructs

Information Processing Model