Guest Editorial: What is the NCLEX really testing?

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It is time for nurse educators to challenge the process for determining content for the NCLEX examination. The current process is that every three years 4000 newly licensed nurses participate in a practice survey administered by the National Council of State Boards of Nursing (NCSBN).¹ The test is primarily hospital and medical-surgical based. There is no distinction made based upon the type of nursing preparation of the new graduate—diploma, Associate Degree, Baccalaureate Degree, or educated outside of the United States. These survey results are then used to determine content allocations for the next examination. This is one reality.

The other reality is that the current health care environment is focused on evidence-based practice, including nursing practice. The premise of this movement is that nursing faculty should be teaching, testing and practicing those elements that are supported by a research base of effectiveness. Furthermore, educators should be preparing nurses for what this evidence base suggests is needed in the health care system. Specifically, education should drive competency testing which then should drive practice.²

The current NCLEX testing methodology has seriously reversed this sound educational process. Instead of testing content that nurses need to know now and in the future, it is testing what new graduates are doing the first six months after graduation. This is putting the cart before the horse.

The licensing examinations of all health professionals—not just nurses—should reflect what practitioners need to know to practice evidence-based care in the realities of well-documented health needs. One only has to read recent reports from the Institute of Medicine (IOM) to realize that health professionals are failing patients and families in this arena. Three recent reports from the IOM, Crossing the Quality Chasm, To Err is Human, and Health Professions Education, document the current crisis in our health care system related to lack of quality, patient errors, and inadequately prepared health professionals. In these reports, the IOM recommends sweeping changes in each aspect of the problem with reformed and transformed educational and care-giving systems. Such transformation will not come about if the critically important nurse licensing examination tests content related to this failing system of care, rather than the content that will help to transform the system.

A clear example of this problem is evident in the revisions to the 2004 NCLEX-RN test plan, in which the number of questions devoted to the “Psychosocial Integrity” category was dramatically reduced. This category, which contains content related to psychiatric–mental health nursing, has been reduced from the previous range of 10% to 22% of overall content to a range of 6% to 12% of total content. This significant change comes at a time when mental health issues are emerging as a major source of disability and morbidity for children, adults and the elderly and there is ample evidence to support this.³, ⁴, ⁵

This is a health care reality and nurses are on the forefront of potentially improving the lives of their patients and families, but only if they are educated to intervene in this critical aspect of care.

New nurses are clearly not addressing this aspect of care based on the NCLEX Practice Analysis of the activities of new graduates.⁶ That is why these items were reduced in the current examination. Further evidence of this emerges when the new graduates were asked to rate the importance of 18 distinct knowledge categories necessary for their performance. The category of social sciences, defined as “knowledge of the emotional, psychological, spiritual and social functioning of human beings” ranked 15th on the list with only the categories of chemistry and physics, nursing research, and economics scoring lower. The fact that entry-level nurses demonstrate a reduction in the performance of nursing activities and a decreased priority for needs related to the psychosocial integrity of patients is nothing short of an indictment of the existing process, given the substantial research evidence documenting that this is the most significant area of unmet need.

So the issue is: should we continue to propagate unprepared practitioners by testing new graduates based on the inadequate performance of our most recent graduates, or should we be teaching and testing based on the evidence-based care needed by patients and families? With the existing system it should come as no surprise that new graduates are not integrating complex issues; clearly they are still attempting to master the most basic of nursing skills. They are, of course, new graduates. It is also no surprise that they are not focusing on the psychosocial needs of their patients because they are still trying to acquire basic psychomotor skills. Once nurses become comfortable in the psychomotor domain of knowledge, they are then able to move on to mastery of other important areas of care. Finally it is no surprise that many nurses do not understand or value research and have had little or no training to help them find evidence on which to base their practice.⁷ Why should we expect anything different given the current NCLEX process?

Most importantly, it should be noted that while NCSBN states that the licensure examination is not intended to drive practice or education, it surely does drive both. For example, many nursing programs report the reduction of psychiatric–mental health didactic and clinical content in their curriculum due to the change in the NCLEX. NCSBN must be fully responsible for both the intended and unintended consequences of the examination it constructs, and we, the educators, must hold them to this responsibility. These issues are substantive and important not only to nursing but to the health and well-being of individuals, families and communities. Thus there are three questions to consider:

The realities speak for themselves. It is now time to take collective action on behalf of the profession.

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References 

1. Aucoin J , Treas L . Assumptions and realities of the NCLEX-RN . Nurs Educat Persp . 2005;26:268–271
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2. Institute of Medicine . Health professions education (a bridge to quality) . Washington (DC): The National Academies Press; 2003;
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3. New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America, final report, DHHS Pub. No. SMA-03-3832, Rockville, Maryland, 2003
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4. US Department of Health and Human Services . Mental health (A report of the surgeon general) . Rockville (MD): Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999;
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5. World Health Organization . The World Health Report 2001—Mental Health (New understanding, new hope) . Geneva: Author; 2001;
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6. Smith J , Crawford L . Report of findings from the 2002 RN Practice Analysis (Linking the NCLEX-RN examination to practice) . Chicago (IL): National Council of State Boards of Nursing; 2003;
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7. Pravikoff D , Tanner A , Pierce S . Readiness of US nurses for evidence-based practice . Am J Nurs . 2005;105:40–51
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