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TEST CONSTRUCTION AND PREPARATION OF STUDENTS FOR NCLEX® AND CERTIFICATION EXAMINATIONS
One of the outcomes of prelicensure nursing programs is for graduates to pass an examination that measures their knowledge and competencies to engage in safe and effective nursing practice. At the entry level for professional nursing, graduates take the NCLEX-RN® (National Council Licensure Examination for Registered Nurses) or, if graduating from a practical or vocational nursing program, they take the NCLEX-PN® (National Council Licensure Examination for Practical Nurses). Certification validates knowledge and competencies for professional practice in a specialized area of nursing. As part of this process, nurses may take certification examinations that assess their knowledge and skills in a nursing specialty such as critical care or pediatric nursing. Other certification examinations measure knowledge and competencies for advanced practice, for teaching, and for administrative roles. As students progress through a nursing program, they should have experience with tests that are similar to and prepare them for taking licensure and certification examinations when they graduate.
Because the focus of the NCLEX and most certification examinations is on nursing practice, the other advantage to incorporating items of these types in teacher-made tests is that it provides a way of assessing whether students can apply their theoretical learning to clinical situations. Teachers can develop items that present new and complex clinical situations for students to critically analyze. Items can focus on collecting and analyzing data, setting priorities, selecting interventions, and evaluating outcomes; providing patient-centered care; communicating with patients, their families, and other healthcare providers; documenting care; teaching; and other processes fundamental to nursing practice. This type of testing is a means of assessing higher and more complex levels of learning and provides essential practice before students encounter similar questions on licensure and certification examinations.
The chapter includes examples of items written at different cognitive levels, thereby avoiding tests that focus only on recall and memorization of facts, and sample stems 142that can used for clinically oriented test items. The types of items presented in this chapter are similar to those found on the NCLEX and many certification tests. By incorporating items of these types on tests in nursing courses, teachers help students acquire experience with this type of testing as they progress through the program, preparing them for taking licensure and certification examinations as graduates. The reader should keep in mind that Chapter 7, Assessment of Higher Level Learning, presented other ways of assessing higher level learning.
The chapter begins with an explanation of the NCLEX test plans in use at the time this edition of the book was prepared (2019). NCLEX and certification examinations are updated every few years to keep current with practice. Based on the most recent practice analysis, which documented the complex decisions nurses make when caring for patients, the National Council of State Boards of Nursing (NCSBN) is exploring use of innovative types of test items to evaluate clinical judgment—the Next Generation NCLEX project (NCSBN, 2019a). Readers are advised to refer to the NCLEX and certification test plans in use when developing examinations and quizzes for their own nursing students.
NCLEX Test Plans
In the United States and its territories, graduates of nursing programs cannot practice as RNs or as practical nurses (PNs) or vocational nurses (VNs) until they have passed a licensure examination. These examinations are developed by the NCSBN based on extensive analyses of the practice requirements of RNs and licensed practical nurses (LPNs) or vocational nurses (LVNs). Items are piloted and tested extensively to ensure they are valid, reliable, and legally defensible, including an analysis of potential biases such as those related to ethnicity and gender (Woo & Dragan, 2012). The licensure examination results then are used by the state boards of nursing as one of the requirements for practice in that state or territory.
NCLEX-RN Test Plan
In developing the NCLEX-RN, the NCSBN conducts an analysis of the current practice of newly licensed RNs across clinical areas and settings. This is a continuous process allowing the licensure examination to stay current with the knowledge and competencies needed by entry-level nurses. To ensure that the NCLEX-RN measures the essential competencies for safe and effective practice by a newly licensed RN, the NCSBN reviews the test plan or blueprint every 3 years (NCSBN, 2018). For the most recent revision of the test plan, 2,275 newly licensed RNs prioritized how frequently they performed 142 nursing activities and rated the overall importance of each activity. Findings are used to develop the NCLEX-RN test plan and items on the test.
143Client Needs
Test items on the NCLEX-RN are categorized by client needs: (a) safe and effective care environment, (b) health promotion and maintenance, (c) psychosocial integrity, and (d) physiological integrity. Two of the categories, safe and effective care environment and physiological integrity, also have subcategories. The client needs represent the content tested on the examination.
Safe and Effective Care Environment
In the safe and effective care environment category, two subcategories of content are tested on the NCLEX-RN: (a) management of care and (b) safety and infection control. In the management of care subcategory, the test items focus on providing and directing nursing care that enhances care delivery to protect clients and healthcare providers. Examples of content tested in this category include advance directives; advocacy; assignment, delegation, and supervision; case management; collaboration with the interdisciplinary team; concepts of management; confidentiality/information security; continuity of care; establishing priorities; ethical practice; informed consent; legal rights and responsibilities; and performance improvement (quality improvement) among others (NCSBN, 2019b). In the NCLEX-RN, 17% to 23% of the items assess management of care.
In the safety and infection control subcategory, test items focus on prevention of accidents, emergency response planning, ergonomic principles, handling hazardous and infectious materials, reporting incidents and irregular occurrences, safe use of equipment, standard precautions, and use of restraints, among others (NCSBN, 2019b). Between 9% and 15% of the items on the NCLEX-RN relate to safety and infection control.
Health Promotion and Maintenance
The second category of client needs is health promotion and maintenance. Between 6% and 12% of the items on the NCLEX-RN relate to health promotion and maintenance. There are no subcategories of needs. Examples of content tested in this category are the aging process, ante/intra/postpartum and newborn care, developmental stages and transitions, health promotion and disease prevention, lifestyle choices, physical assessment techniques, and others (NCSBN, 2019b).
Psychosocial Integrity
The third category of client needs, psychosocial integrity, also has no subcategories. This category focuses on nursing care that promotes the emotional, mental, and social well-being of clients experiencing stressful events, and the care of patients with acute and chronic mental illness. Examples of content tested include abuse, behavioral 144interventions, coping, crisis intervention, cultural awareness and influences on health, end-of-life care, grief and loss, mental health, sensory and perceptual alterations, and therapeutic communication and environment (NCSBN, 2019b). Six percent to 12% of the items on the NCLEX-RN ask questions about psychosocial integrity.
Physiological Integrity
The final client needs category, physiological integrity, is a significant content area tested on the NCLEX-RN. Items in this category focus on nursing care that promotes physical health and comfort, reduces risk potential, and manages health alterations. Four subcategories of content are examined by these items on the NCLEX-RN:
1. Basic care and comfort: In this area, items focus on comfort measures and assistance with activities of daily living. Related content includes assistive devices, elimination, mobility and immobility, nonpharmacological comfort interventions, nutrition and oral hydration, personal hygiene, and rest and sleep. Six percent to 12% of the items are on basic care and comfort.
2. Pharmacological and parenteral therapies: Items focus on adverse effects, contraindications, side effects, and interactions; blood and blood products; calculating dosages; central venous access devices; medication administration; parenteral/intravenous therapy; pharmacological pain management; and total parenteral nutrition. More test items are included on the NCLEX-RN in this subcategory than the others in the physiological integrity category. Between 12% and 18% of the items relate to pharmacological and parenteral therapies.
3. Reduction of risk potential: The content in this subcategory relates to measures for reducing the risk of developing complications or health problems. For example, items relate to diagnostic tests; laboratory values; potential for complications from diagnostic tests, treatments, and procedures, and from surgical procedures; and system-specific assessments, among others. In the test plan, 9% to 15% of the items relate to these content areas.
4. Physiological adaptation: The last subcategory includes nursing care of patients with acute, chronic, or life-threatening physical health problems. Between 11% and 17% of the test items relate to physiological adaptation. Sample content areas are alterations in body systems, fluid and electrolyte imbalances, hemodynamics, management of illness and medical emergencies, pathophysiology, and unexpected responses to therapies (NCSBN, 2019b).
Integrated Processes
Five processes that are fundamental to nursing practice are integrated throughout each of the categories of the test plan: (a) nursing process, (b) caring, (c) communication 145and documentation, (d) teaching and learning, and (e) culture and spirituality (NCSBN, 2019b). Thus, there can be test items on teaching patients and the nurse’s ethical and legal responsibilities in patient education as part of the management of care subcategory, teaching nursing assistants about the use of restraints in the safety and infection control subcategory, health education for different age groups in the health promotion and maintenance category, and teaching about diagnostic tests in the reduction of risk potential subcategory. The other processes are integrated similarly throughout the test plan. Many of the items on the NCLEX examinations are developed based on clinical scenarios. Those scenarios can involve any age group of patients in acute care hospitals, long-term care, community health, or other types of settings.
Cognitive Levels
The taxonomy for the cognitive domain is used for developing and coding items on the NCLEX-RN (NCSBN, 2019b). This taxonomy was presented in Chapter 1, Assessment and the Educational Process. The majority of items are at the application (applying) and higher cognitive levels (NCSBN, 2019b). This has implications for testing in prelicensure nursing education programs. Faculty members should avoid preparing only items that require remembering and understanding facts and specific information on their tests. Although some low-level questions are essential to assess students’ knowledge, test items also need to ask students to use their knowledge and analyze data and clinical situations to decide on approaches to take. Test blueprints can be developed to list not only the content and number of items in each content area but also the level of cognitive complexity at which items should be written. An example of a blueprint of this type was provided in Exhibit 3.3 in Chapter 3, Planning for Testing.
NCLEX-PN Test Plan
The test plan for the NCLEX-PN is developed and organized similarly to the RN examination. In the most recent practice analysis for this test plan, LPN/LVNs who were newly licensed were asked how frequently they performed 151 nursing activities and the importance of those activities (NCSBN, 2019c). The activities were then used as the framework for the development of the test plan for the PN examination.
The test plan is structured around client needs and integrated processes fundamental to the practice of practical and vocational nursing. The same four client needs categories are used for the NCLEX-PN with differences in some of the subcategories, related content, and percentage of items in each category and subcategory. In the safe and effective care environment category on the NCLEX-PN, 18% to 24% of the items are on coordinated care, and 10% to 16% are on safety and infection control. Between 6% and 12% of the items assess the second category of client needs: health promotion and maintenance. Nine percent to 15% of the items 146on the NCLEX-PN address psychosocial integrity. The last category of client needs, physiological integrity, has four subcategories similar to the RN test plan: basic care and comfort (7%–13% of the items), pharmacological therapies (10%–16% of the items), reduction of risk potential (9%–15% of the items), and physiological adaptation (7%–13% of the items; NCSBN, 2016). Five processes are integrated throughout the test: (a) the clinical problem-solving process (nursing process), (b) caring, (c) communication and documentation, (d) teaching and learning, and (e) culture and spirituality. Items are developed at all cognitive levels with the majority written at the application or higher levels of cognitive abilities, similar to the NCLEX-RN test plan (NCSBN, 2016).
Types of Items on the NCLEX Examinations
The NCLEX examinations contain multiple-choice items and alternate item formats. Earlier chapters described how to construct each type of item used on the NCLEX: multiple-choice (Chapter 5, Multiple-Choice and Multiple-Response); the alternate formats of multiple-response (Chapter 5, Multiple-Choice and Multiple-Response), fill-in-the-blank (for calculations), and ordered response (Chapter 6, Short-Answer (Fill-in-the-Blank) and Essay); and hot-spot and chart or exhibit (Chapter 7, Assessment of Higher Level Learning). Some items include audio and the candidate listens to an audio clip and selects a response; other items have graphics. Any of the types of items might include a table, a chart, an image, or sound as part of the item. These items with multimedia have the capacity to assess higher levels of thinking and do so more authentically than a text-based item.
The NCLEX-RN Detailed Test Plan (National Council of State Boards of Nursing, 2016, 2019b) provides valuable information about the practice activities used for developing the items and content areas assessed in each of the categories and subcategories on the examination. As described earlier, the NCSBN analyzes the current practices of newly licensed RNs and PNs or VNs across clinical specialties and settings and the knowledge needed for safe and effective practice. This analysis identifies nursing activities that are used frequently by entry-level nurses and are important to ensure patient safety. Development of the NCLEX using these practice activities provides evidence of validity as a measure of entry-level nursing practice.
The NCLEX-RN Detailed Test Plan includes a list of the activity statements and related content for each category and subcategory. This information is of value in developing items for tests in a nursing program. For example, in the safety and infection control subcategory, the activity statements describe the practices that RNs use to protect clients and healthcare personnel from health and environmental hazards. An example of one of these activity statements is, “Apply principles of infection control (e.g., hand hygiene, aseptic technique, isolation, sterile technique, universal/standard precautions)” (NCSBN, 2019b, p. 15). A sample test item is also provided with each category and subcategory.
147Administration of NCLEX Examinations
The NCLEX is administered to candidates by computerized adaptive testing (CAT). The CAT model is such that each candidate’s test is assembled interactively as the person is answering the questions. Each item on the NCLEX has a predetermined difficulty level. As each item is answered, the computer reestimates the candidate’s ability based on whether the answer is correct or incorrect (NCSBN, 2019b). The computer then searches the item bank for an item with a 50% chance of being answered correctly by the candidate. This is an efficient means of testing, avoiding questions that do not contribute to determining a candidate’s level of nursing competence.
The standard for passing the NCLEX is criterion referenced. The standard is set by the NCSBN based on an established protocol and is used as the basis for determining whether the candidate has passed or failed the examination. The NCLEX-RN can range from 75 to 265 items, with 15 of those being pretest items that are not scored. After candidates answer the minimum number of items, the testing stops when the candidate’s ability is above or below the standard for passing, with 95% certainty (NCSBN, 2019b). Because the NCLEX is an adaptive test, candidates complete different numbers of items, and therefore the test takes varying amounts of time. If a candidate’s ability has not been determined by the time the maximum number of items has been presented or when the time limit has been reached, the examination then stops.
All RN candidates must answer a minimum number of 75 items. The maximum number they can answer is 265 within a time limit of 6 hours (NCSBN, 2019b). On the NCLEX-PN, PN and VN candidates must answer a minimum of 85 items. The maximum number of items they can answer is 205, during the 5-hour testing period allowed (NCSBN, 2016).
Preparation of Items at Varied Cognitive Levels
When courses have higher level outcomes, tests in those courses need to measure learning at the applying and analyzing levels rather than at remembering and understanding. This principle was discussed in earlier chapters. Items at higher levels of cognitive complexity are more difficult and time-consuming to develop, but they provide a way of evaluating ability to apply knowledge to new situations and to engage in analytical thinking. The majority of items on the NCLEX are written at higher levels of cognitive ability, requiring application of knowledge and analytical thinking.
Students are at a disadvantage if they encounter only test items that ask them to recall facts as they progress through a nursing program. Low-level items assess how well students memorize specific information, not whether they can use that knowledge to analyze clinical situations and arrive at the best decisions possible for those situations. Students need experience answering questions at the application and analysis levels before they take the NCLEX. More important, if course outcomes are at higher levels of cognitive complexity, then tests and other methods need to assess learning at 148those levels. In graduate nursing programs, test items should be developed at higher cognitive levels to assess students’ ability to problem solve and think through complex situations to prepare them for certification examinations they might take as graduates.
When developing a new test, a blueprint is important in planning the number of items at each cognitive level for the content areas to be assessed. By using a blueprint, teachers can avoid writing too many items that require only recall of information. For existing tests that were not developed using a blueprint, teachers can code items using Bloom’s taxonomy or the updated taxonomy of the cognitive domain and then decide whether more higher level items should be added.
Remembering (Knowledge)
In developing items at varying cognitive levels, it is important to remember the learning outcome intended at each of these levels. Questions at the remembering or knowledge level deal with facts, principles, and other specific information that is memorized and then recalled to answer the item. An example of a multiple-choice item at the remembering level follows:
Your patient is taking pseudoephedrine for his stuffy nose. Which of the following side effects is common among patients using this medication?
a. Diarrhea
b. Dyspnea
c. Hallucinations
d. Restlessness
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