The National Council of State Boards of Nursing is transparent about the Next Generation NCLEX(R) (NGN). Example questions for the NGN demonstrate an accurate resemblance to the way nurses think in practice. The logical question to ask at this point is: Will new graduates think this way?
Research conducted over the last 15 years (del Bueno, 2005; Muntean, 2012) and more recently by Kavanagh and Szweda (2017) indicates only 23 percent of new RN graduates are able to think at entry-level expectations regardless of degree earned. This may result in faulty decisions leading to poor patient outcomes. A major fear, applicable also to Practical Nursing/Vocational Nursing faculty, is that new nurse graduates may not be prepared for the NGN. Here is why: If the way faculty have been teaching thinking for decades ill-prepares students for the thinking needed for the NGN, we need to ask: How do we teach clinical judgment (CJ)? Let us turn that fear into opportunity. Let us examine current strategies used to teach thinking and then develop a plan to teach higher levels of thinking to prepare students for CJ as measured on the NGN.
Tanner's (2006) process for CJ includes four steps: noticing, interpreting, responding, and reflecting. This process does not replace the nursing process but provides steps to guide thinking that support the nursing process. Many faculty ask students to apply these four steps to direct their thinking as they answer questions. This approach is helpful but lacks detail. Specific CJ competencies (thinking skills) that must be learned, practiced, and applied for each of the four steps of the model are missing.
Nursing education typically teaches thinking through the nursing process and by asking questions about patient situations. It is assumed that if students answer questions correctly, they are thinking. However, this approach has two problems: 1) the assumption that students are able to think, and 2) what happens when students are asked similar questions repeatedly. The student may reach the correct answer while using faulty thinking, and when the same or similar question is asked over and over again, the student learns to anticipate the question. The goal is to answer the question correctly, rather than to explain one's thinking using a model or framework.
The National Council of State Boards of Nursing (2019) developed a Clinical Judgment Measurement Model (CJMM) using six general cognitive skills that involve recognizing and analyzing cues. Although it may be tempting to ask questions that relate to these skills, for example, to ask, "What information is missing from the patient assessment?", this approach to questioning will not produce self-regulated thinkers with good CJ skills. Students will continue to anticipate questions and be ready with answers. They will not actually learn the specific cognitive skills needed to engage in the six cognitive skills measured by the CJMM.
So, what's the answer? We must first teach a detailed CJ model/framework with specific thinking skills to guide students' thinking while they answer faculty questions. Students must use their own thinking to make decisions (Caputi, 2020) and become self-regulated thinkers, not thinkers who rely on faculty questions to guide their thinking, which leaves them at a loss when faculty are no longer present. For example, for Recognize Cues, students must learn specific CJ competencies such as clustering related information and judging how much ambiguity is acceptable. Students learn these examples of CJ competencies within a framework and model and can apply them independently as needed. Rather than answering questions aligned to the CJMM, students learn CJ competencies that align to the CJMM.
Once students master the CJ competencies, their answers to faculty questions should yield not just the answer but an explanation about how they arrived at that answer using detailed CJ competencies. At this point, asking questions is helpful, but it is best not to ask the same questions repeatedly. The NLN (Forneris & Fey, 2020) has developed the Critical Conversation approach for guiding student thinking and developing reflective practitioners. First, teach the model/framework (Caputi, 2020) described here, and then use Forneris and Fey's Critical Conversations to engage students in meaningful discussions.
Using the process described here can transform the NGN from something to fear to an opportunity to prepare new graduates to improve patient outcomes - not just to pass the NGN. The time is now for all faculty to travel a new path for teaching CJ.
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