At the recent National League for Nursing Education Summit (September 2018 in Chicago), National Council of State Boards of Nursing director of examinations Dr. Philip Dickison presented a powerful and enjoyable overview of the Next Generation NCLEX (NGN). I learned one major lesson from his presentation: There will be a shift away from a primary focus on content and the indirect testing of clinical judgment to a major focus on clinical judgment.
The most intriguing aspect of the change will be in the types of questions asked by the NGN. Dickison presented examples of six item types that are currently being developed and psychometrically studied. As he finished his presentation, I thought: "This is NCLEX 2.0!" What I saw were not only new item types but items that measured clinical judgment at a very different level and in a very different way than is currently the case. The intent of these new item types is to provide higher fidelity, or realism, to the way nurses actually think in clinical practice than current test items provide.
This is an exciting change that will bring with it new challenges for nurse educators. Two questions come to mind: 1) Are students ready for this type of NCLEX? 2) If our students already pass the NCLEX, can we keep doing the same type of preparation for the NGN?
Let's consider some research that suggests the answer to both questions is No. More than 10 years ago, Del Bueno (2005) found that only 35 percent of new graduates were able to think at entry-level expectations, regardless of educational preparation. Kavanagh and Szweda (2017) replicated Del Bueno's research and found that only 23 percent met entry-level expectations. All subjects studied by these researchers had passed the NCLEX-RN.Muntean (2012), noting that novice nurses have difficulty making effective decisions, reported that as many as 65 percent of adverse patient events could be prevented if nurses were better decision-makers.
Although all nursing programs include thinking as part of their curricula (Muntean, 2012), I propose that we look at how we are teaching thinking. Some common learning strategies we use include case studies, active group work in the classroom, nursing care plans, and debriefing after simulation and in clinical postconference. The intent of these and other methods used to teach thinking is to provide practice in the application of thinking. We should continue to use these techniques, but we must understand that, although they are great for applying thinking, students cannot apply thinking if they have never learned a detailed framework and approach to thinking itself.
I have been working with schools of nursing for more than 25 years on the teaching of thinking, but it has only been since 2001 that I realized that faculty expect students to think without first teaching them to think. How do students first learn what clinical judgment is before they are expected to use it? Is teaching the five steps of the nursing process or the four steps of Tanner's (2006) clinical judgment model enough? I suggest that, based on the research results about new graduate thinking, it is not enough. We must drill down to details.
So, what can faculty do? I propose that nurse faculty, at all levels of nursing education, revise their curricula to teach a detailed thinking process that students must employ over and over throughout the nursing curriculum. Just as students practice psychomotor skills until they are perfected, they must do so with thinking skills and strategies.
A new model for teaching clinical judgment is needed, and I offer one example based on a review of the nursing and education literature from the past 20 years. This model has gone through numerous iterations culminating in its current form, which I call the Caputi Model for Teaching Thinking in Nursing(C) (Caputi, 2016, 2018). My approach consists of three layers, from the general to the specific: Benner's novice to expert theory, Tanner's clinical judgment model, and 19 select competencies (thinking skills and strategies). It is proposed as a framework for students to learn what clinical judgment/thinking in nursing is before they are expected to apply clinical judgment.
1. The top layer of the model is Benner's (2001) novice to expert theory. Students are novices when they arrive at the door of the nursing program. As they learn the "rules" of nursing, they apply them as learned to all patients regardless of context. In the next step, advanced beginner, how a rule is applied depends on the situation. To make the transition from rule-based thinker to situation-based thinker, students must have guided practice using the second and third layers of the model.
2. The second layer uses the four steps of Tanner's clinical judgment model, first published in 2006. Learning the four broad steps of clinical judgment -- noticing, interpreting, responding, and evaluating - is helpful, but still not enough to actually learn clinical judgment.
3. The details of thinking are learned in the third layer, which consists of 19 thinking skills and strategies, or thinking competencies. These competencies, needed to actually apply thinking to nursing situations, were derived from various research-based sources, including the NCLEX Practice Analysis (National Council of State Boards of Nursing, 2018), the Nursing Executive Center (Berkow, Virkstis, Stewart, Aronson, & Donohue, 2011), and other nursing and education literature (Dickison et al., 2016; Levett-Jones et al., 2010).
Integrating research-supported thinking competencies is the missing piece of teaching clinical judgment. Some examples of thinking competencies are judging how much ambiguity can be tolerated in a given situation, distinguishing relevant from irrelevant information, and recognizing inconsistencies. These and the other thinking competencies are reviewed, applied to everyday situations, applied to simple nursing situations, used in the clinical setting, and used repeatedly throughout the nursing program, in all learning environments, as students become self-regulated thinkers.
Students in the first nursing course learn these thinking competencies as they are learning new nursing content. The key is that all faculty also learn the three-layered model and continue to use it throughout the curriculum, providing students with a consistent approach and detailed language related to how they are thinking. In so doing, students are applying the model to develop deep thinking rather than trying to answer a variety of questions posed in various ways by different faculty.
As I applied this model with dozens of my own nursing students, it became apparent they were able to think at a much higher level than with my previous approach, which used a list of questions I asked repeatedly. Students were able to analyze a situation and arrive at credible decisions by using an established, detailed thinking framework. Using the detailed competencies and their related language, students were able to describe the thinking that drove their decisions. I have since used this model with faculty in various schools of nursing who report similar results.
I challenge my nursing faculty colleagues to implement such a framework, not just in prelicensure nursing programs but in RN-to-BSN programs as well. Doing so will help BSN completion students harness their thinking into a process that can be applied not only to patient care but to their emerging leadership roles. And let us not forget students in master's in nursing education programs. Educators in schools of nursing must learn a detailed approach to thinking to teach clinical judgment to their students, and nursing professional development practitioners must also learn an approach to clinical judgment to assist new and experienced nurses to further their thinking abilities. This process can also be used in new graduate orientation programs, particularly in light of Kavanagh and Szweda's (2017) findings. Learning to think does not end upon graduation from a prelicensure nursing program.
As we enter a new era and take on the challenge of the NGN, we must think using new era thinking. Our old approaches will no longer work. We must embrace a new way of doing by reframing our own thinking to be open to new ideas. The Dickinson presentation convinced me that nursing students can no longer be expected to apply thinking in nursing if we do not first teach them how to think. We must make this change - not just for the purpose of preparing graduates to pass the NCLEX but also to provide safe patient care that will improve patient outcomes and decrease the failure-to-rescue rate. Improving patient outcomes is actually the driver for this very much needed change. Isn't that the goal for all of us in nursing education?
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