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What You Need to Know About Changes to the NCLEX Exam

Gayle Morris, BSN, MSN
Updated March 21, 2023
    The NCLEX exam is changing spring 2023 to better emphasize clinical judgment. Here's what you can expect on the new test.
    Credit: Pekic / Getty Images

    Every new nurse must pass the National Council Licensure Examination (NCLEX) to get their state license. The test determines if a nursing graduate has the skills and knowledge to practice nursing. To meet this goal, the National Council of State Boards of Nursing (NCSBN) developed and continues to update a sound and legally defensible examination.

    Ongoing assessments of the NCLEX exams use research from entry-level nurses. The organization then refines the tests to keep pace with rapidly changing healthcare.

    The result of these assessments has led to the Next Generation NCLEX (NGN). The NCSBN is in the final stages of research and testing. The new test questions and format will be released no earlier than 2023.

    So what does this mean for nursing students? This page covers updates to the test and how nursing students can prepare for the NGN.

    Next Generation NCLEX: Updates and What’s Changing

    The NCSBN Next Gen NCLEX is expected to have significant changes when it’s released in 2023 or later. The new test hopes to evaluate new graduates better on their critical thinking skills for nurses and determine if they are ready to make the right decisions about patient care.

    About every three years, the NCSBN assesses the NCLEX. The goal of the test is to assess new graduates’ readiness and ability to work in a hospital. Recently, NCSBN found that nurses routinely care for critically ill patients and are responsible for complex decisions. Findings from the 2017 RN Nursing Knowledge Survey confirm this.

    The NCSBN then researched and tested questions. Data was gathered during the 2017-2018 NCLEX exam period. Students taking the registered nurse (RN) and practical nurse version of the test were asked if they would complete a special research section. These test questions were not used in their NCLEX score.

    The aim of the new test questions is to better simulate a hospital’s work setting and set the groundwork for better patient outcomes. The focus is on evaluating nursing students’ judgment, decision-making, and critical thinking skills.

    However, the test does not explicitly test clinical knowledge. Instead, students must have nursing clinical skills to succeed, so clinical knowledge must be used to get the correct answer.

    During data gathering, researchers tested these new types of questions. They found test-takers took around one minute to answer each one.

    Conceptual Changes

    The Next Generation NCLEX measures the clinical judgment model. It starts with assessing a client’s needs.

    The nurse forms a hypothesis, refines it, and evaluates the outcomes. When the outcome is unsatisfactory, the hypothesis is re-evaluated and refined again. The nurse determines the correct action, which would result in strong clinical decision-making.

    Nurses must consider several environmental and individual factors. For example, environmental factors include the local setting, observations, medical records, task’s complexity, and cultural competence in nursing. Individual nursing factors must also be accounted for, including a nurse’s personal skill level, prior experience, and knowledge.

    The exam tests if a nurse recognizes relevant information from different sources.

    1. 1The test questions give information and the nurse must decide what is relevant and what is irrelevant.
    2. 2Next, the questions lead the test-taker to clinical presentations where they prioritize the information.
    3. 3They must also determine what more is needed to establish a hypothesis.
    4. 4The questions then lead the nurse through prioritizing hypotheses according to urgency. The test-taker must generate solutions that would result in a desirable outcome.
    5. 5Finally, the candidate indicates the appropriate action and evaluates the outcomes. The test also asks to consider what other interventions may have been more effective.

    These conceptual NCLEX changes were brought about in a pilot study in 2016, where the NCSBN discovered that clinical knowledge is essential but not enough to support clinical judgment. They define clinical judgment as “the observable outcome of decision-making and critical thinking.”

    The pilot study also demonstrated that the development of clinical judgment is progressive. There was no single element that predicted ability. It was the combination of different elements that translated to better judgment.

    Poor judgment may be a significant contributing factor to a 2016 Johns Hopkins Medicine study which suggested medical errors are the third leading cause of death in the U.S. Researchers analyzed death rate data over an eight-year period.

    Safety experts calculated more than 250,000 deaths each year are due to medical errors. This is higher than respiratory diseases as a cause of death. Increased clinical judgment skills can lessen these errors and increase patient safety.

    New Item Types

    To adequately test this information, the NCSBN is also changing the types of questions on the test. NCLEX study plans should begin incorporating these new formats.

    Based on results from the special research section, the NCSBN has approved five new types of questions to measure nursing clinical judgment on the NGN. They do not believe that the new types of questions will be difficult for students who are technologically inexperienced.

    One change that may make it more like the real world is the split screen. The case information will be presented on the left side and the questions on the right.

    The test is expected to keep some of the current NCLEX-style questions and will remain computer adaptive. These new question types include:

    1. Extended multiple response

    This is an advanced version of a “select all that apply” question, but it has more options. While they might not be enjoyable for students, they are an excellent way to reproduce the real world.

    When a patient is deteriorating, you can’t choose just one option from four or five. This also allows the NCSBN to use partial credit on these types of questions.

    2. Extended drag-and-drop

    These are similar to the current drag-and-drop questions. They allow the test-taker to move options into answer spaces. However, in the new format, not all the options may be used to answer the question, requiring a deeper understanding of the material to make a sound clinical judgment.

    3. Cloze (drop-down)

    This question allows the test-taker to choose one option from a drop-down list but now there can be more than one drop-down list. The candidate is presented with a case study and then asked for as many as six responses. The drop-down lists may be inserted inside a table, chart, or sentence, and the list can include words or phrases.

    4. Matrix (grid)

    A matrix is a group of items arranged in a rectangle. The items solve a problem or measure an item. Within the Next Generation NCLEX, students are provided with a scenario and data. They must then make judgments and check the appropriate boxes in the matrix.

    For example, on the left side of the screen is the clinical data. On the right side is a matrix of potential clinical tests. The candidate would choose which are essential, nonessential, and harmful.

    5. Enhance HotSpot

    Using this type of question, the candidate can answer questions by highlighting predefined words. The test-taker reads a part of a client chart, then selects words in the chart that answers the question.

    For example, the student is presented with clinical data. They must then click specific words or phrases within the data to answer the question.

    NCSBN has also added a follow-up research section to the exam. This again does not count toward the student’s NCLEX test results.

    This section collects data to help develop scoring rules and determine how much time students take on each item. The special research section varies each quarter depending on the information the NCSBN is seeking. There are no consequences for not participating and students do not need to prepare for the special research section.

    The NCSBN recommends educators begin incorporating the clinical judgment measurement model into their simulation labs, standard written exams, and educational settings. At this time, they do not know how the changes will impact the pass rate.

    They anticipate the earliest the new format will be released is spring 2023.

    Scoring Structure

    The Next Gen NCLEX will also have a new scoring method. Currently, the NCLEX items are scored as either all incorrect or all correct. Using a scoring model that accounts for multiple answers will allow for partial credit. It will go into effect in April 2023.

    Educators should keep up to date and prepare their students with NCLEX practice questions.

    The scoring model used is different from the passing standard. The passing standard defines the students who pass the NCLEX and those who don’t. A panel of nursing subject-matter experts determines the standard. Experts expect more details of how this will occur and how it will affect the pass rate closer to 2023.

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    Why Is the NCLEX Changing?

    The NCLEX is a measurement tool used by each state to determine if new nursing school graduates have the knowledge and skills needed to practice nursing. Every three years, the NCSBN conducts an analysis that highlights the changes in healthcare.

    Because nurses are responsible for decisions and healthcare changes rapidly, the NCLEX must adequately measure knowledge and clinical critical thinking skills made by new nurses.

    Changes to the NCLEX were discussed in 2009 after several research reports revealed that current clinical decision-making models may require updating.

    Over the following six years, the NCSBN collaborated on two studies. Evidence proved that the importance of clinical judgment is highly rated by newly licensed RNs, supervisors, facilities, and educators.

    The combination of this data and the rising number of medical errors led the NCSBN to research new testing methods.

    How Will NGN Impact Nursing Curriculum

    Nursing school curriculums are expected to change slightly as schools scramble to prepare students for the NGN. However, the NCSBN does not believe it will be necessary for nursing schools to fully change their curriculum. It is only necessary to continue to teach clinical judgment effectively to prepare new graduates for the examination and their clinical position after licensure.

    Each nursing college must meet accreditation standards, but there is some flexibility in how concepts are taught. The NCLEX is the last standard a new nursing degree graduate must meet before being licensed to practice by the state board of nursing.

    While somewhat similar, the NCSBN clinical judgment measurement model (NCJMM) does not replace the nursing process. It is an evidence-based framework that tests nursing graduates.

    The NCSBN hopes the NCJMM helps nursing educators evaluate clinical judgment in the classroom. It can also be used to develop teaching methods associated with decision-making and critical thinking to bolster clinical judgment.

    How Do I Prepare for NCLEX Next Gen?

    With the change in testing format and additional questions added to the NCLEX, nursing students may be concerned about preparing for the Next Generation NCLEX.

    Students can help themselves by seeking resources to develop clinical reasoning skills. The basis of clinical judgment tested in the Next Gen NCLEX uses critical thinking and decision-making skills as their base. While these changes are not expected until 2023, it is wise for nursing students to start preparing now.

    The NCSBN hopes this new model will better evaluate nursing graduates to care for more complex patients as the healthcare system evolves.

    Technological advancements and a rising number of senior adults with chronic diseases have impacted the healthcare system. The Next Generation NCLEX will help nursing schools and students to raise the level of patient care and improve patient outcomes.