The NCLEX measures the foundational knowledge and skills needed for safe nursing practice for entry-level nurses, regardless of academic background. Every three years NCSBN conducts a practice analysis to evaluate the knowledge, skills, and abilities needed for entry-level nurses and to evaluate the validity of the test plan that guides content distribution of the licensure examination. The practice analyses have highlighted changes in healthcare including an increase in acutely ill clients. Nurses are responsible for a significant proportion of the judgments and decisions made in healthcare and newly licensed nurses are required to make progressively more complex decisions about patients.
In 2009, NCSBN reviewed several research reports and engaged in professional discussions with nursing experts on the importance of clinical judgment in the nursing profession. This led to funding a thorough literature review on the subject and culminated in a comprehensive white paper. The report provided an overview of the current nursing theories and models of clinical decision-making, along with empirical research on factors that affect decision-making in nursing. Specifically, the report found that 50% of entry-level nurses were involved in practice errors (Smith & Crawford 2002) and a subsequent study by Brennan et al. (2004) found that 65% of entry-level nurse errors were related to poor clinical decision-making. In addition, Saintsing et al. (2011) reported that only 20% of employers were satisfied with decision-making abilities of entry-level nurses.
Between 2012 and 2014 NCSBN collaborated on two studies as part of a strategic job analysis. The fundamental conclusions from these studies provided further evidence of the importance of clinical judgment in entry-level nursing. One major finding was that clinical judgment was one of the top five required skills needed upon entry into the field. Interestingly, two other high priority skills in the top five were problem solving and critical thinking skills, which themselves are vital to clinical judgment. The other two were related to professional communication and active listening.
The RN Nursing Knowledge Survey from 2017 provided additional evidence of the importance of clinical judgment. The overall importance of clinical judgment was rated between ‘important’ and ‘critically important’ by newly licensed RNs, RN educators and RN supervisors. It was also similarly rated across the facility categories of hospital, long-term care, community-based care, and other. The overall result is consistent with previous research showing that clinical judgment is essential to the safe practice of nursing at the entry level.
A panel of subject matter experts consisting of PN Educators, PN Clinicians and Nurse regulators was convened to compare the activity statements included in the 2018 LPN/VN Practice Analysis to the elements of the NCSBN Clinical Judgment Measurement Model (NCJMM). The findings indicated that the entry-level PN was expected to provide care using the nursing process framework and make the necessary clinical judgments within their scope of practice. The NCJMM elements that were most often cited as essential to the practice of the entry-level PN were recognize cues, analyze cues and take action. The element least associated with the entry-level PN activities was prioritize hypotheses. Given these findings, the Next Generation NCLEX item types and NCJMM represent a valid and reliable measurement of PN competence and will be incorporated into the NCLEX-PN examination.
