Item Writing for Nurse Educators 3031302109, 9783031302107

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Item Writing for Nurse Educators Vicki Moran

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Item Writing for Nurse Educators

Vicki Moran

Item Writing for Nurse Educators

Vicki Moran Trudy Busch Valentine School of Nursing Saint Louis University Saint Louis, MO, USA

ISBN 978-3-031-30210-7    ISBN 978-3-031-30211-4 (eBook) https://doi.org/10.1007/978-3-031-30211-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This book is about writing effective items for nursing education. Whether the testing is used for assessment of knowledge learned in a nursing curriculum, evaluation of program learning for nurses in the clinical setting, or preparation for certification exams, the purpose of the book is to assess cognitive learning in items prepared by examinations. Current studies have validated that nursing faculty lack the resources and knowledge required to write items (Bristol et al., 2018; Moran et al., 2022; Tarrant et al., 2006). Therefore, effective item writing from development to evaluation is essential for any nurse educator. References • Bristol, T. J., Nelson, J. W., Sherrill, K. J., & Wangerin, V. S. (2018). Current state of test development, administration, and analysis: A study of faculty practices. Nurse Educator, 43(2), 68–72. https://doi.org/10.1097/NNE.0000000000000425 • Moran, V., Wade, H., Moore, L., Israel, H., & Bultas, M. (2022). Preparedness to write items for nursing education examinations: A national survey of nurse educators. Nurse Educator, 47(2), 63–68. https://doi.org/10.1097/NNE.0000000000001102 • Tarrant, M., Knierim, A., Hayes, S.  K., & Ware, J. (2006). The frequency of item writing flaws in multiple-choice questions used in high stakes nursing assessments. Nurse Education in Practice, 6(6), 354–363. https://doi.org/10.1016/j.nepr.2006.07.002 Saint Louis, MO, USA

Vicki Moran v

Acknowledgment

I want to express my deepest gratitude to Sidney Smith, BSN, RN, CCRN, for her assistance in the review and editing of the book. She dedicated herself to learning and teaching other nursing students as a prelicensure nursing student. After graduating with her BSN in 2020, she continues demonstrating the true passion of a nursing scholar, professional, and diabetes advocate.

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Contents

1 Item Writing Basics �������������������������������������������������������� 1 1.1 Introduction�������������������������������������������������������������� 2 1.2 Stem�������������������������������������������������������������������������� 2 1.3 Answer���������������������������������������������������������������������� 5 1.4 Distractors ���������������������������������������������������������������� 5 1.5 Rationales������������������������������������������������������������������ 5 References��������������������������������������������������������������������������12 2 Bloom’s Taxonomy ����������������������������������������������������������15 2.1 Background of Bloom’s Taxonomy��������������������������16 2.2 Defining the Levels of Bloom’s Taxonomy, Learning Objectives, and Item Writing to the Various Nursing Education Levels������������������18 References��������������������������������������������������������������������������30 3 Items  for the National Council Licensure Examination (NCLEX)����������������������������������������������������31 3.1 Multiple-Choice Questions (MC) ����������������������������32 3.2 Multiple Response or Answer or Option Questions (MR)��������������������������������������������������������33 3.3 Cloze (Drop-Down)��������������������������������������������������36 3.4 Drag and Drop (Ordering or Pick from a List) ��������38 3.5 Enhanced Hotspot (Highlighting) ����������������������������41 3.6 Matrix/Grid ��������������������������������������������������������������41 3.7 Additional Types ������������������������������������������������������43 Reference ��������������������������������������������������������������������������44

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Contents

4 Case Study Development ������������������������������������������������45 4.1 Case Study����������������������������������������������������������������46 4.2 NCJMM and Test Items for Nursing Education ������48 4.2.1 Relationships of Layer 3 and Items for Case Studies��������������������������������������������50 4.3 Stand-Alone Items����������������������������������������������������51 4.3.1 Bowtie ����������������������������������������������������������52 4.3.2 Trend Item����������������������������������������������������52 References��������������������������������������������������������������������������53 5 Item and Exam Analysis��������������������������������������������������55 5.1 Item Analysis������������������������������������������������������������56 5.1.1 Point Biserial Correlation Coefficient (Point Biserial Index [BPI])��������������������������57 5.2 Reliability of Exams ������������������������������������������������60 5.3 Scoring and Answer Changing����������������������������������62 5.4 Other Considerations for Items and Exam Construction��������������������������������������������������������������63 References��������������������������������������������������������������������������64 6 Mapping����������������������������������������������������������������������������65 6.1 Introduction��������������������������������������������������������������66 6.2 Mapping Exam Items to Course Objectives (COs) or Learning Outcomes (LOs) ������������������������66 6.3 Mapping Exams to Student Learning Outcomes (SLOs)������������������������������������������������������67 6.4 Mapping Exam Items to NCLEX Blueprint ������������68 References��������������������������������������������������������������������������70

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Item Writing Basics

Abstract

The chapter will review the basic details in item writing of multiple-choice questions (MCQs), including stem, answer, distractor, and rationale. Tests have a powerful influence on student learning. Therefore it is important to develop tests with items that are aligned with educational goals and objectives. The introduction of the Clinical Judgment Model and its impact on nursing education will be discussed. Keywords

Stem · Answer · Distractor · Rationale

Learning Objectives In this chapter, the learner will learn about 1. Crafting a stem, answer, and distractors for item writing multiple-­choice questions (MCQs) for nursing education. 2. Summarize how rationales benefit the learner and the writer. 3. Describe pearls and pitfalls to item writing basics. 4. Understand the Clinical Judgment Model in item writing for nursing education.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_1

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1  Item Writing Basics

1.1 Introduction Item writing for nursing education is often referred to as an art and skill. Learned in graduate programs, item writing is a challenge for any nurse educator who wants to determine if knowledge learned can be applied. A recent study by Moran et  al. (2022), surveyed nurse educators who reported a lack of consistency and confidence in item writing. Many nurse educators rely on test banks that accompany a text or modify existing items instead of writing questions with the assumption that the NCLEX-­ style test bank questions have been validated. Nurse educators who write their own questions are more likely to write them at higher cognitive levels (Tarrant et  al., 2006). Nursing-specific guidelines from item writing for nursing education and the National Council Licensure Examination (NCLEX) are available by the National Council of State Boards of Nursing (NCSBN, 2013). Additional information regarding these can be found on the NCSBN website, www.ncsbn.org. The NCLEX test plan blueprint for nurse educators, since 2016, has included a section of item writing exercises including steps to item writing. Of note, if writing items for a certification product, be sure to review the most up-to-date blueprint for that exam, readily available on the certifying body’s website. Reviewing the exam blueprint will aid in including topics covered and the types of question being asked.

1.2 Stem A test item is the basic unit of any exam. It usually starts with a command or question that has a set of conditions to respond to and the manner of scoring. The literature contains information related to test-item development toward testing professionals but not specifically for nursing (Haladyna, 2002; Haladyna & Rodriguez, 2013). When developing an exam or questions to validate learning has occurred, it is important to test on pertinent content a nurse needs to know. For example, if signs and symptoms of a particular disease are necessary for the nurse to know, then the question should focus on a question that asks that information. In

1.2 Stem

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development of the assessment of knowledge or test, focus on the important content for the learner to know. Content decisions will drive the number and topic areas of the items to be developed. The amount of attention given to evaluating a content area should reflect its importance. All item writers should remember that it is often impractical to cover all testing topics in equal lengths. Item writing flaws are prevalent in nursing items. These are commonly referred to as violations to accepted writing standards or guidelines. Therefore, it is important to write items and have them evaluated by another educator comparing the questionable items to the learning objectives. Testable material should focus on • Course or clinical objectives • Important topics covered • Testable items should be representative of the curriculum (National Board of Medical Examiners (NMBE), 2021) Creating test items is a skill that requires critical thinking and clear writing. Development of the item to test the learner’s cognitive ability is the goal of professional education. Learners should be able to read the stem and use problem-solving abilities to answer the question. Learners must acquire the necessary knowledge and skills and apply these to more complex tasks expected in the nursing profession. In nursing education, the stem of the test item is of importance. It is usually written in third person with the nurse being part of the stem. Recall that first person is the use of “I” and second person is the use of “you.” Third person is consistently used in nursing item writing and should focus on the role of the nurse. As such, the stem usually starts with “the nurse is caring.” Stems should contain a subject and a verb. A quality stem is a reasonable sentence that is clear and precise and represents a complete thought. It should contain language necessary to present a singular objective. The stem should address only one problem or question. It is most beneficial to have one or two introductory sentences in the stem to help clarify the item.

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An item writer should focus on the purpose of the item and what is needed cognitively to answer the question. The item can address knowledge needed to perform the task or can be related to priority of tasks needed. The stem should be worded in such a way as to query one correct answer. Therefore, the introductory material in the stem provides a background for the question introduced. The question should focus on the elements of the nursing process such as assessment, intervention, and evaluation. The other integrated processes of nursing involve caring, communication and documentation, and teaching and learning. Language complexity should always be considered when writing stems. Several concepts that affect stems should be addressed. An active voice is critical to the profession of nursing; therefore, a writer should avoid a passive voice in the stem. The use of word frequency and family is important in nursing education. High blood pressure versus hypertension can impact performance of an item. Words high on the word frequency list are more likely to be read and understood than words low on the word frequency list. Long words and sentences affect performance on an item. Avoiding negative words is also imperative to stems. Experts agree that multiple-choice questions (MCQs) should be prepared as questions rather than incomplete sentences. An educator, when constructing a stem, should consider the following questions: • When would this matter? • In what situation might this apply? Another way to think about developing a stem is to think about the prompt question. These can include: • • • •

What is the nurse’s best action? What finding should the nurse prioritize? What should the nurse do next? What is the nurse’s priority?

By asking the prompt question, the educator can then engineer the stem based on the question. This is often referred to as reverse engineering the stem.

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1.3 Answer The correct response or answer or key should be listed. The correct choice should be simply and unambiguously stated. There should be no leading information that would help or influence the reader to select the correct choice other than by knowing the correct answer. In addition, it should be grammatically correct.

1.4 Distractor Distractors or incorrect responses are more difficult than writing the answer. The incorrect choices should differentiate between students that know the correct answer and students that are guessing. To do so, distractors need to be “attractive” options for the student, such as common errors or misunderstandings. Strong distractors must be • Homogeneous • Unequivocally wrong, but still plausible • Parallel to the key in terms of length, tone, grammar, and specificity Homogeneous distractors should be options that are similar such as plausible diagnosis’ rather than including both a diagnosis and pathogen. Distractors should not contain never language or verbs that are inconsistent with nursing practice. Verb examples include require, force, insist, punish, or interrupt.

1.5 Rationale The rationale is an excellent teaching tool. Student learning occurs with the explanation. Rationales should have a few sentences that explain why the answer is correct, and why the distractors are incorrect. Good explanations should not simply state that the key is correct, or that the distractors are wrong, they should explain why each option was correct or incorrect. Rationales should be a prose of writing that can stand alone, be logical, and be gram-

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matically correct. Avoid referring to the choice by the letter assigned. This should be a nice piece of writing. Refer the learner back to the stem if necessary. Most important to the rationale is to avoid simply writing that the other distractors are incorrect. Explaining that the options are not related to disease process or intervention is more appropriate than just stating the distractor is incorrect. This aids the learner in understanding and using the cognitive process. Pearls and Pitfalls Pitfalls to avoid in stem creation: • Use of “you” or patient names such as Mrs. Smith. Refer to the clinician as the nurse. • Gender: Unless gender specific. • Age: Unless developmental or pediatric/gerontology considerations. • Stereotyping: Nurse is not always a female—avoid “she.” • Sensitive terminology: Handicapped, crippled. • Slang: Pop for soda. • Brand names: Gatorade or Lasix. • Elitism: yacht, polo. • Roles: Women cook, men lead. • Giving the client a name: Mrs. Brown or Susan. • Too much information that is not relevant to the question. • Being too vague that the answer can be answered from multiple perspectives. • Negative stems. A common example is the “all of the following are true except” question. These types of multiple-choice items are often confusing to students and emphasize the wrong answers. • Teaching in the stem. The test item’s purpose is to appraise the student’s knowledge, not cater to it. Teaching gives away too many clues as to the correct response and deflects from the examinee’s critical thinking abilities. • Opinionated items. Stems should present objective facts to be tested, not evaluate subjective opinions.

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Pitfalls to avoid in answer creation: • Making the answer more elaborate by using more details, more words or using technical terminology than the other distractors. • Making the incorrect answer shorter or longer than the other options. • Writing answer choices that are not in the same category, such as a laboratory assessment when other items are vital signs. • Use of absolutes such as “always, never, only all.” • Avoid the use of vague terms such as frequently, occasionally, rarely, usually, commonly, etc. • Keep answer choices short and stems long. If the answer and distractor starts with “the patient,” then place the words “the patient” in the lead in. • Use of similar or repeating words from the stem. Pitfalls to avoid in distractor creation: • Avoid the temptation to create distractors by simply flipping the correct answer. Flipping correct information: examples include increased rather than decreased, high rather than low. • Actions that nurses will not perform. • Admonishing client, ignoring client feelings. • Nonsensical distractors. • Use of synonyms. • More detail in the correct option than the incorrect options. • Mutually exclusive options (one option should not cancel out another). • Overlapping numerical ranges: examples include 5–10, 9–12, 11–15. • Avoid the use of “All of the above” or “None of the above.” If using “All of the above,” this should be used in a multiple answer or select all that apply (SAA) questions.

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Pitfalls to avoid in rationale creation: • Implying that because the answer is correct, the distractors are incorrect. • The presence of one correct answer does not automatically rule out other options being correct. • Decontextualized blocks of text (e.g., copied and pasted from source material). • Use prose that can stand alone as a teaching tool. • Providing too much information—stay focused on answering the question. • Sparse explanations. • Circular explanations (“the [nursing action] is a priority because nurses must always prioritize [the same nursing action]”). • Any explanation that does not genuinely answer the question Why? Clinical Judgment Model Introduction There is an interrelationship that exists between critical thinking, clinical reasoning, and clinical decision-making. All of these cognitive processes rely on the nurse making a clinical judgment, or decision about care being delivered. The exact definition has not been defined (Connor et al., 2022). The outcome of the cognitive mental process is clinical judgment. National Council State Boards of Nursing (NCSBN) identified three acceptable paradigms for nursing clinical judgment: the Benner’s Intuitive-Humanistic Model, which was later integrated into the Tanner’s Model; Dual Process Reasoning Theory by Croskerry 2009, anchored in the Harbison’s cognitive continuum theory; and the Oppenheimer and Kelso’s Information Processing Model (Dickison et al., 2019). In constructing the framework for clinical judgment, NCSBN built a conceptual model based on the acceptable paradigms in nursing. “Because clinical judgment is a higher-order cognitive construct, the NCSBN Clinical Judgment Model (NCSBN-CJM) had

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to synthesize cognitive theories of the construct from the literature, facilitate an understanding of the construct, and lay theoretical grounds for defining and assessing clinical judgment (Dickison et al., 2016). Nurses with the skills to recognize, analyze, hypothesize, respond, and evaluate appropriately should be able to deliver excellent care within a multitude of contexts since they are more likely to make good clinical judgments (Dickison et  al., 2016)” (Dickison et al., 2020). “In 2020, the NCSBN changed the name of the model to the NCSBN-Clinical Judgment Measurement Model (NCSBN-­ CJMM) and the model serves as the platform for test-item construction about clinical judgment” (Dickison et al., 2020). The model contains layers that represent the clinical judgment of nurses. “Layer 0 contains two naturally observable entities: client needs that initiate the process of clinical judgment and clinical decisions to complete the process. Layers 1–3 (the cognitive layers) depict the analysis of an iterative or recursive series of cognitive operations. Layer 1 is a single entity that comprises the entirety of clinical judgment, which is defined by the observable entities depicted in Layer 0 and the unobservable cognitive operations depicted in Layers 2–3. Layer 2 represents an iterative process of three cognitive operations: form hypotheses, refine hypotheses, and evaluate hypotheses. Layer 3 divides these operations into independent, recursive operations necessary for completion of each Layer 2 operation. For example, recognize cues and analyze cues (Layer 3) are necessary to form hypotheses (Layer 2). Layer 4 (the context layer) contains a set of contextual factors that may impact the performance of the cognitive operations within the model) (Dickison et al., 2019). The model was the basis of testing of new test items for clinical judgment in pre-licensure students. Since 2018, NCSBN has asked first time testers to complete a special study section of the exam, completing reliability and validity of items related to the CJMM. After 3 years of testing, NCSBN is planning to administer at least three case studies or stand-alone items in the National Licensure Examination for Registered Nurse (NCLEX-RN) in April of 2023 (NGN, n.d.).

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Current Research A traditional Delphi methodology to seek consensus from clinical reasoning experts from the fields of nursing, medicine, and physical and occupational health determined that 56 essential elements are needed in clinical reasoning (Joplin-Gonzales & Rounds, 2022). Current practice of teaching clinical judgment in pre-licensure nursing programs seems to congregate into two categories: case studies and simulation (Nielsen et  al., 2022). Additional research is needed to develop essential elements of the Clinical Judgment Model and its application to nursing care and outcomes. Examples Incomplete statement format for stem: • A normal blood pressure range is ______________________. Direct question format for stem: • Which of the blood pressure ranges are used for diagnosing hypertension? Teaching in the stem example: • A nurse is caring for a client with type 1 diabetes, a chronic disorder where beta cells are destroyed. Use of you or names examples: • You are the nurse caring for a 38-year-old female … • The nurse is caring for Martha Smith … Flipping the distractor examples:

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• Which of the following are vital signs consistent with anaphylactic shock? (a) Elevated blood pressure and decreased heart rate. (b) Decreased blood pressure and elevated heart rate. (c) Normal blood pressure and normal heart rate. (d) Elevated blood pressure and elevated heart rate. (e) Decrease blood pressure and decreased heart rate. Vague question example: • Which laboratory data is most important for a nurse to report? (a) White blood cell count 2.9 mL. (b) Hematocrit 44%. (c) Blood urea nitrogen 1.2 mg/dL. (d) Potassium 3.5 mmol/dL. Correct answer is longer and rationale example: • A nurse is caring for a patient taking lisinopril. Which statement is used in teaching the client about the medication? (a) “The medication will slow the heart rate.” (b) “It will improve blood flow to the kidneys.” (c) “The medication affects the conversion of the angiotensin I to angiotensin II in the kidneys, lowering the blood pressure.”*. (d) “It will be used when there are three consecutive elevated blood pressure readings.” * Correct answer Rationale: Lisinopril is an angiotensin converting enzyme (ACE) inhibitor which affects the renin angiotensin aldosterone

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system (RAAS) by preventing the conversion of angiotensin I to II, which is a potent vasoconstrictor. As a result of the mechanism, the patient’s blood pressure is decreased. The medication does not improve blood flow to the kidneys. As the blood pressure decreases, most patients will also have a slower heart rate but the medication affects the blood pressure primarily. A patient is usually prescribed an agent to lower the blood pressure after three consecutive elevated blood pressure readings but not only lisinopril. Summary The key to item writing is understanding and adhering to the item writing basics. A nurse educator should be writing their own items, using this chapter as a guide. Item writing is a learned process.

References Connor, J., Flenady, T., Massey, D., & Dwyer, T. (2022). Clinical judgement in nursing–an evolutionary concept analysis. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16469 Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of state boards of nursing clinical judgment model into nursing educational frameworks. The Journal of Nursing Education, 58(2), 72–78. https://doi.org/10.3928/01484834-­20190122-­03 Dickison, P., Haerling, K. A., & Lasater, K. (2020). NCSBN clinical judgment measurement model clarification. The Journal of Nursing Education, 59(7), 365. https://doi.org/10.3928/01484834-­20200617-­02 Dickison, P., Lou, X., Kim, D., Woo, A., Muntean, W., & Bergstrom, B. (2016). Assessing higher-order cognitive constructs by using an information-­processing framework. Journal of Applied Testing Technology, 17, 1–19. Haladyna, T. M., Downing, S. M., & Rodriguez, M. C. (2002). A review of multiple-choice item-writing guidelines for classroom assessment. Applied Measurement in Education, 15(3), 309–333. Haladyna, T. M., & Rodriguez, M. C. (2013). Developing and validating test items. Routledge. Joplin-Gonzales, P., & Rounds, L. (2022). The essential elements of the clinical reasoning process. Nurse Educator, 47(6), E145–E149. https://doi. org/10.1097/NNE.0000000000001202

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Moran, V., Wade, H., Moore, L., Israel, H., & Bultas, M. (2022). Preparedness to write items for nursing education examinations: A National ­Survey of nurse educators. Nurse Educator, 47(2), 63–68. https://doi.org/10.1097/ NNE.0000000000001102 NBME. (2021). NBME item-writing guide: Constructing written test questions for the health sciences. Retrieved from https://www.nbme.org/item-­ writing-­guide NCSBN. (2013). NCLEX examination webinar series: Item writing and item review. https://www.ncsbn.org/recorded-­webinar/nclex-­examinations-­ webinar-­series-­nclex-­item-­writing-­and-­item-­review NCSBN. (n.d.). NGN News–Winter 2022. Retrieved from https://www. ncsbn.org/publications/ngn-­news-­winter-­2022 Nielsen, A., Gonzalez, L., Jessee, M. A., et al. (2022). Current practices for teaching clinical judgment: Results from a National Survey. Nurse Educator, 48(1), 7–12. Retrieved from http://ovidsp.ovid.com/ovidweb. cgi?T=JS&PAGE=reference&D=ovftz&NEWS=N&AN=00006223-­ 900000000-­98929. https://doi.org/10.1097/NNE.0000000000001268 Tarrant, M., Knierim, A., Hayes, S. K., & Ware, J. (2006). The frequency of item writing flaws in multiple-choice questions used in high stakes nursing assessments. Nursing Education in Practice, 6(6), 354–363.

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Bloom’s Taxonomy

Abstract

The chapter will focus on Bloom’s taxonomy, a model used in education. Bloom’s taxonomy is used in education to develop learning objectives which describe what students will be expected to learn. In item writing, the educator needs to write items to the learning objectives. Keywords

Bloom’s taxonomy · Learning objectives · Item writing

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_2

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Learning Objectives In this chapter, the learner will learn about 1. Understand the development of Bloom’s taxonomy. 2. Describe how learning objectives are related to knowledge attainment. 3. Identify different levels of Bloom’s taxonomy. Describe pearls and pitfalls of writing items to Bloom’s taxonomy.

2.1 Background of Bloom’s Taxonomy Bloom’s taxonomy is a hierarchical model that categorizes learning objectives into varying levels of complexity, from basic knowledge and comprehension to advanced evaluation and creation. In 1956, Benjamin Bloom with collaborators Max Englehart, Edward Furst, Walter Hill, and David Krathwohl published a framework for categorizing educational goals: Taxonomy of Educational Objectives (1956). The original six major categories include knowledge, comprehension, application, analysis, synthesis, and evaluation. A revision of Bloom’s taxonomy was published in 2001 with the title: A Taxonomy for Teaching, Learning, and Assessment points to a more dynamic conception of classification. The authors of the revised taxonomy justified the learning process as dynamic and proposed “action words” to describe the cognitive processes by which thinkers encounter and work with knowledge. See Fig. 2.1. The new categories include remember, understand, apply, analyze, evaluate, and create. As the student obtains additional knowledge about a topic, thinking skills increase from the lowest part of the pyramid to the highest level.

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Fig. 2.1  Bloom’s taxonomy

2.1  Background of Bloom’s Taxonomy

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2.2 Defining the Levels of Bloom’s Taxonomy, Learning Objectives, and Item Writing to the Various Nursing Education Levels Bloom’s taxonomy meshes learning objectives and the cognitive processes of the different levels. Objectives are essential to the teaching and learning process. Learning objectives should be brief, simple, and concrete statements about what the student will be able to do by the end of the lesson. It is an expected outcome and essential for effective teaching. Therefore, the learning objectives should be strategically placed in nursing curriculums, practice environments, and continuing education based on the knowledge necessary for the nurse. The remember category is used to assess the knowledge of facts or to define a concept. In the learning objective, educators should use an active verb in the statement. At this level, a student should recall, memorize, or state facts and basic concepts. The understand category is used to explain ideas or concepts. In the learning objective, educators should use an active verb such as describe or explain in the statement. At this level, a student should be able to identify, discuss, or classify a nursing concept. The apply category is when knowledge obtained from the other two categories is used in a new situation. In the learning objective, educators should use active verbs such as interpret, demonstrate, or implement the information to apply it to a clinical situation. At this level, a student should be able to determine how the knowledge pertains to the situation. Vignette-based items such as a detailed patient or scenario provide a necessary vehicle demonstrating higher-order thinking skills. For medium-to-high stakes summative examinations, use of vignette-based items requiring application of knowledge is preferable to simple recall items (NBME, 2021). There are benefits of using application items on exams. Application items are used to validate or authenticate the exams by justifying the ability to use knowledge to solve problems. In addition, application items are more likely to be focused on important information necessary for the student to know outside

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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the examination. Finally, application items differentiate between learners who have memorized information but have difficulty using the knowledge in the clinical situation and those who are able to apply the knowledge learned. Learners need to be able to differentiate between relevant and irrelevant information (NBME, 2021). The analyze category is used to draw on connections to ideas using comparing and contrasting. In the learning objective, educators should use active verbs such as differentiate, organize, and examine. At this level, a student should be able to use the knowledge obtained and draw connections to the different clinical situations. The two last categories in Bloom’s taxonomy, evaluate and create, are difficult to assess in item writing. The evaluate domain requires a decision and to critically evaluate the decision. Examples of activities to evaluate knowledge are completed with papers, problem sets, class discussions, or concept maps. Activities such as research projects, essays, or website designs are used to assess the creative domain of Bloom’s taxonomy. This domain requires the students to make, build, design, or generate something new. Examples Remember Level Question A nurse is caring for a patient with high blood pressure. Which blood pressure is expected? 1. 2. 3. 4.

110/70 120/80 130/70 140/80 In a remember level question, the student is asked to recall or remember the information. The answer is 140/80. High blood pressure is elevated with either a systolic greater than 130 mmHg or diastolic greater than 90 mmHg. Notice that the focus was on the systolic reading rather than the diastolic.

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Understand Level Question A nurse is caring for a patient diagnosed with hypertension and taking lisinopril 10 mg QD PO. In teaching the patient about the medication, which statement is included in the plan of care? (a) “It will decrease your sodium levels and your heart rate.” (b) “It will lower your blood pressure by affecting the kidneys.” (c) “It will increase blood flow to your heart and reduce the blood pressure.” (d) “It will elevate the hemoglobin level, increasing oxygen consumption by the tissues.” In an understanding level question, the student is asked to explain, interpret, or summarize ideas or concepts. The key is that lisinopril lowers the blood pressure by blocking the conversion of angiotensin I to angiotensin II. Lisinopril does not affect the sodium levels but can cause the increase of potassium, causing hyperkalemia. Lisinopril does not increase blood flow to the heart. A medication, such as a vasoconstrictor, increases blood flow to the heart but it does not reduce but increase the blood pressure. Lisinopril does not elevate the hemoglobin levels nor increase oxygen consumption by the tissues. Application Level Question A nurse is caring for a patient diagnosed with hypertension and taking lisinopril. Which laboratory value should be reported immediately to the provider prior to administering the medication? (a) (b) (c) (d)

Hemoglobin 15 g/dL Potassium 5.7 mmol/L Creatinine 1.04 mg/dL Magnesium 2.0 mg/dL In an application level question, the student is expected to pull concepts together. The student should know that lisinopril affects the potassium level and in this question, the potassium level is elevated above the normal range. The other laboratory values are within normal ranges.

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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Analyze Level Question A nurse is caring for a patient diagnosed with hypertension and taking lisinopril. The patient reports muscle weakness, nausea and vomiting, and chest pain. Which nursing action should the nurse implement immediately? (a) Call the prescriber and report the assessment findings. (b) Review the potassium laboratory assessment in the electronic health record (c) Prepare the patient for an electrocardiogram (d) Administer a 500 cc 0.9% saline infusion over 20 min In the analysis level question, the student is expected to apply the knowledge and make a decision on the care. The patient is experiencing signs and symptoms of an elevated potassium level. Before calling the prescriber, the nurse should be prepared to present all the pertinent information related to the health care provider, which includes the potassium level. Preparing the patient for the electrocardiogram is not the immediate intervention. The administration of a saline infusion is not warranted at this time. Pearls and Pitfalls There are a few pearls of information that are pertinent to writing items using Bloom’s taxonomy. A summative assessment or exam should focus on application of knowledge as it can test recall and reasoning from Bloom’s taxonomy. By incorporating realistic vignettes or scenarios, an educator can use the item to assess real-­ life decisions, supporting problem-based learning. It is important to recognize that application-based items and testing require more writing and testing time and may not detect specific deficiencies of the learner. The verb choice does not define the level of Bloom’s taxonomy. Many educators think that prioritizing such as who should the nurse assess first should be classified as an application or analysis level question. Depending on the scenario, it could be an understood question. See the example below. A nurse has received a report on four patients. Which patient does the nurse assess first?

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2  Bloom’s Taxonomy

(a) A patient with a heart rate of 99 beats/min (b) A patient with a temperature of 97.8 °F (36.5 °C) (c) A patient with a blood pressure of 118/78 mmHg (d) A patient with an oxygen saturation of 80% In this question, the student needs to know the parameters of vital signs to understand how to answer the question. Therefore, it is a question at the understanding level and not an application level question. Another pitfall to avoid is the assumption that if there are multiple responses or answers to a question, then the item is at the application level. Again, this is a false assumption. Multiple response questions can be written at the remember level. Educators must pay close attention to the various levels of Bloom’s taxonomy and make sure the question is at the appropriate level. Recall that lower level questions are appropriate for specific learners. Early learners should be evaluated on the knowledge learned and overtime should be evaluated on the application of the information learned in situations. To determine if a question is at the application level, an educator should write a question based on a scenario and then ask how the nurse should assess, teach, intervene, or evaluate the situation. By doing this, the nurse needs to apply the information learned early into the situation. Here is an example of vignette or scenario-based stem: The nurse is caring for a woman who is being evaluated in the emergency department for shortness of breath and left lower extremity pain with ambulation. She states that she recently traveled from Paris, France and returned yesterday. She is currently taking levothyroxine 100 mcg by mouth daily. The questions can focus on the following: • Signs and symptoms of a diagnosis • Treatment course • Evaluation of successful treatment or follow-up interventions

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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To write items to the analysis level, the educator should know how to determine a relationship among the concept(s), know the effects of the situation, identify patterns, and understand the meaning of information in a client or nursing practice situation. It is important to present this information as a scenario and look for the relationship in the scenario. More example stems for Bloom’s taxonomy of apply and analysis are included which focus on the nursing process (assessment, diagnosis, intervention, and evaluation) and the integrative process of nursing: caring, communication, and teaching/learning. Nursing Process: Assessment Understand stems: • Which statement reflects the assessment phase of the nursing process? • Which nursing behavior reflects the assessment phase of the nursing process? Apply stems: • The nurse is completing a [health history, physical assessment] on a client who reports [symptoms]. What question should the nurse ask that would be most effective to help determine the cause of the symptoms? • The nurse is assessing a client who presents with [condition/ signs/symptoms]. What procedure will the nurse perform as part of a system specific assessment on this client? • The nurse is caring for a client with [disease/condition] who is being monitored via telemetry. The nurse observes the ­following: [image of rhythm strip]. What [cardiac rhythm, abnormality] is this client experiencing? • The nurse is completing a health history on a [age/client]. What question should the nurse ask the [mother/client] to determine whether the [child/client] is meeting expected age-­ appropriate developmental milestones?

2  Bloom’s Taxonomy

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Nursing Process: Diagnosis Apply stem: • A client presents with [signs/symptoms]. Which nursing diagnosis is most accurate? Analyze stem: • Upon assessment of a client, the nurse identifies the following signs and symptoms: [list signs and symptoms]. What is the priority nursing diagnosis? Nursing Process: Planning Apply stems: • When planning care for a client with [condition/disease, risk factor, clinical manifestations], which nursing intervention would the nurse include to [state goal] • A nurse is planning to [action]. Which action by the nurse demonstrates [understanding, lack of understanding] of [principle, action, behavior] for this client? • A nurse is planning to [action]. Which [component, data] should the nurse use to safely complete this task? • The nurse providing care to a client who is [describe behavior] would expect to provide which intervention to promote [describe goal]? Analyze stems: • The nurse is planning care for a client with [disease/condition] and exhibiting [signs and symptoms]. Based on these findings, what prescription should the nurse implement first? • The nurse is caring for a client with [disease/condition] and exhibiting [signs and symptoms]. Which outcome is the priority for this client?

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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Nursing Process: Implementation Apply stems: • The nurse is preparing to [action, procedure] a client with [disease, condition]. The client exhibits [signs/symptoms]. What action by the nurse would be [appropriate or priority]? • The nurse is [intervention] for a client. What action by the nurse characterizes appropriate follow-through for safety and accuracy of this intervention? • A client has been prescribed a [drug classification], [drug generic (trade name)], for [disease, condition, clinical manifestation]. The client states “[statement related to risk or concern about the drug].” What should be the priority nursing action? • A client is [scheduled for something, asked to do something]. The client tells the nurse, “[statement by client sharing concern or information].” What is the best [action or response] of the nurse? • A nurse [sees, observes, tests, asks, hears, etc.]. What intervention should the nurse implement to promote [define]? • A client diagnosed with [disease, condition] has been receiving [treatment] for [period of time]. The nurse evaluates the following information. [insert image of data—such as table of lab results, X-rays, etc.] Which additional findings should the nurse expect on further assessment? Analyze stem: • A client diagnosed with [disease, condition] has been receiving [treatment] for [period of time or not]. The nurse evaluates the following information. [insert image of data—such as table of lab results, X-rays, etc.] Which nursing action should the nurse initiate? • A client diagnosed with [disease, condition] has been receiving [treatment]. The nurse evaluates the following information. [insert image of data—such as table of lab results, X-rays, etc.] Which health care provider prescription would the nurse anticipate?

2  Bloom’s Taxonomy

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• The nurse is providing teaching to a client receiving [treatment]. The teaching plan should include directions to [action] when which of the following occurs? • The nurse is caring for a client with [disease or condition] who has [sign/symptom]. Which assessment finding(s) would support the [administration of medication (include class of med or generic) and nursing intervention]? Nursing Process: Evaluation Apply stem: • The nurse is caring for a client with [disease, condition, signs/ symptoms] who has received [treatment] over [period of time]. Which question would assist the nurse in evaluating the client’s response to treatment? Analyze stems: • The nurse is administering a prescribed [drug classification], [drug generic name (brand name)], for [condition]. Which finding indicates that the therapeutic level has been reached? • The nurse is evaluating the response of a client with [condition/disease, risk factor, clinical manifestations] to [treatment, intervention]. Which follow-up intervention is a priority? • The nurse is evaluating the response of a client with [condition/disease, risk factor, clinical manifestations] to [treatment, intervention]. Which response is an [expected/unexpected] outcome? • The nurse is caring for a client with [disease, condition]. Which finding would indicate that the client is developing complications?

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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Caring Application stem: • A client states, “[concern].” Which nursing intervention demonstrates caring toward this client? • The nurse observes a client demonstrating “[disease, condition, behavior, signs/symptoms].” Which nursing intervention demonstrates caring toward this client? Analysis stem: • A nurse is performing a health assessment on a client who presents with [signs and/or symptoms]. Which question will assist the nurse in incorporating [approach, concept, teaching] into the client’s plan of care? Teaching/Learning Apply stems: • A client is prescribed a [drug classification], [drug generic name], for [condition]. What should the nurse teach about this medication? • A client is prescribed a [drug classification], [drug generic name], for [condition]. What [adverse effect, side effect, therapeutic response] should the nurse instruct the client to [report, observe for] when taking this medication? • The nurse is teaching a client [about …, how to do…]. Which response from the client indicates that teaching has been effective? • The nurse is developing a teaching plan for a client with [condition, signs/symptoms]. Which teaching [strategy, tool, factor, statement, instruction] should the nurse consider?

2  Bloom’s Taxonomy

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Analyze stems: • The nurse instructs a client who has been prescribed a [drug classification], [drug generic name (brand name)], for [condition], about the expected therapeutic response. [Which statement by the client indicates that teaching is effective? or which statement by the client indicates the need for further teaching?] • A client is prescribed a [drug classification], [drug generic name], for [condition]. What statement by the client indicates that teaching [about dosage, administration, side effects, adverse effects] is effective? • The nurse instructs a client who has been prescribed [drug classification], [drug generic name], for [condition], how to avoid adverse effects from this medication. Which statement indicates that the teaching has been effective? • A client is prescribed a [drug classification], [drug generic name], for [condition]. What [adverse effect or side effect] should the nurse instruct the client to report when taking this medication? • A nurse performs [intervention] for a client. Which action indicates a lack of knowledge of [performing the intervention]? • The nurse is teaching a client [about …, how to do…]. Which response from the client indicates that teaching has been effective? • The nurse is teaching a client [about …, how to do…]. Which response by the client indicates that further teaching is required? • The nurse is developing a teaching plan for a client with [condition, signs/symptoms]. Which assessment data should the nurse consider? • Which statement by the client indicates a need for further teaching of [disease, condition, procedure, etc.]?

2.2  Defining the Levels of Bloom’s Taxonomy, Learning…

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Therapeutic Communication Application stems: • The nurse is caring for a client with [disease, condition, signs/ symptoms]. The [client/family member] [states, is observed…]. Which response by the nurse is most therapeutic? • A client states, “[client statement].” The nurse determines that the therapeutic technique [state technique] is most appropriate when responding to the client. Which response by the nurse represents this technique? • The nurse is caring for a client with [disease, condition, signs/ symptoms]. The [client/family member] [states, is observed…]. Which response by the nurse is most therapeutic? Analysis stems: • The nurse states to a client, “[statement].” What phase of the therapeutic relationship is represented? • The nurse is caring for a client who states, “[statement].” Which response by the nurse reflects [therapeutic communication technique]? • The nurse is caring for a client who states, “[statement].” Which response by the nurse reflects [barrier to communication]? • The nurse is caring for a client with [type of deficit, impairment]. What technique would support therapeutic communication? Summary Use of Bloom’s taxonomy can be beneficial to the nurse educator. By recognizing the level of the learner and developing items to the learner’s ability, a nurse educator can aid in developing the critical thinking skills necessary in the professional nursing role.

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References Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. In Vol. handbook I: Cognitive domain. David McKay Company. NBME Item Writing Guide (2021). Retrieved from https://www.nbme.org/ item-writing-guide.

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Items for the National Council Licensure Examination (NCLEX)

Abstract

Writing items for the nursing examinations should be congruent to items a student will be exposed to on the National Council Licensure Examination (NCLEX). This chapter describes the types of items and pearls and pitfalls to avoid when developing those items. Keywords

Item types · Cognitive levels · Item development

Learning Objectives 1. Identify the different item types used on nursing examinations and NCLEX. 2. Describe the different item types with examples and address the level of cognitive levels.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_3

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3  Items for the National Council Licensure Examination (NCLEX)

3.1 Multiple-Choice Questions (MC) A multiple-choice question is a survey question designed to answer a single option. It typically has a stem, one correct answer, and three other incorrect responses. 1. The stem describes more specifically the question, or problem. The stem should be grammatically error-free with relevant information. 2. The correct answer should be relevant to the stem and should not consist of qualifiers like “always” and “some.” 3. The incorrect responses are also called “distractors.” The three distractors should be in line with the correct answer. These distractors should usually be common misconceptions that the target audience may have. Bloom’s Taxonomy This item type can address remember, understand, apply, and analyze levels of testing. Pearls and Pitfalls The correct choice should be simply and unambiguously stated. Strong distractors must be homogeneous, unequivocally wrong but still plausible, and parallel to the correct answer in terms of length, tone, grammar, and specificity. Explaining why the distractors options are incorrect using prose that can stand alone as a teaching tool. Avoid stating that the distractors are incorrect. Example A nurse is caring for a client with high blood pressure. The nurse is preparing to give lisinopril. Which intervention is the priority? (a) Review the allergies in the electronic health record. (b) Assess the laboratory assessments of the client (Key). (c) Administer the medication as prescribed. (d) Evaluate the client’s knowledge of the medication.

3.2  Multiple Response or Answer or Option Questions (MR)

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Bloom’s Taxonomy: Apply Rationale: The nurse should assess the laboratory assessments prior to administering any medication. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor and is a competitive inhibitor of ACE, which prevents the conversion of angiotensin I to angiotensin II, reducing blood pressure. Angiotensin II stimulates the adrenal cortex to produce aldosterone and the pituitary to produce antidiuretic hormone. Aldosterone induces sodium reabsorption and, in turn, water reabsorption through internal mineralocorticoid receptor activity. These drugs tend to raise the serum potassium level and reduce the glomerular filtration rate (GFR), which is assessed by creatinine levels. Allergies should be reviewed but this is not the highest priority of administering a medication. Administration of the medication should occur after the laboratory assessments and blood pressure are determined. Teaching about the client’s knowledge is important but not immediately before administering the medication. When evaluating this question, notice that the stem has a few statements to support the question. Each option starts with a verb to be consistent. The rationale is explicit and thorough, providing enough information to support the answer. Each distractor has a rationale addressing why the option is incorrect. The question is an application question as the learner needs to know about the medication and how it affects the function of the kidneys.

3.2 Multiple Response or Answer or Option Questions (MR) Multiple response questions or multiple answer questions are the kind of questions that provide a list of possible answer options, and respondents can select all options that are true. The types of questions are often referred to as Select all that apply (SAA) or choose one or more options. Up to 10 options are included in the development of the question. Similar to the multiple-choice questions, it has a stem, multiple answers, and a rationale. There can be multiple types of multiple response questions. See Table 3.1 for additional information.

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3  Items for the National Council Licensure Examination (NCLEX)

Table 3.1  Types of multiple response questions Multiple response— select all that apply (SAA) Up to 10 options that can apply

Multiple response—select a Multiple response grouping number (N) item Grouping of body system such as Select a N number respiratory or cardiac system on of findings that is the one side and the other side can specified in the have relevant interventions or statement or evaluation items for that body question system

Bloom’s Taxonomy This item type can address remember, understand, apply, and analyze levels of testing. Pearls and Pitfalls Do not assume that a question that has multiple answers is a higher-level question. See below for an example. These questions should follow guidelines for single option multiple-choice questions except there are multiple answers. Example A nurse is completing a morning assessment of a client. Which is included in the assessment? Select all that apply. (a) Head-to-toe assessment (key) (b) Vital signs (key) (c) Percentage of food consumed on breakfast tray (key) (d) Documentation of visitors in the room (e) Calculate protein needs for next meal (f) Obtain weight (key) Bloom’s Taxonomy: Understand Rationale: During a morning assessment, the nurse is responsible for completing a head-to-toe assessment, vital signs, documenting percentage of food consumed on breakfast tray, and weight.

3.2  Multiple Response or Answer or Option Questions (MR)

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Documenting visitors is not necessarily a nursing function. Calculation of protein should be completed by the dietician or nutritionist and is not a nursing function. This question is a multiple response question. The level of Bloom’s taxonomy is understood. A learner would need to know what is included in a morning assessment and then choose the correct activities. To increase the level of Bloom’s taxonomy, the educator should include another concept or medical condition to the stem. Example A nurse is caring for a client who has a history of congestive heart failure, hypertension, and peptic ulcer disease. The morning electrocardiogram (EKG) rhythm strip is Fig. 3.1. Which medications are expected in the medication administration record? (a) Furosemide (key) (b) Famotidine (key) (c) Acetaminophen (d) Ibuprofen (e) Isoniazid (f) Acyclovir Bloom’s Taxonomy: Apply Rationale: Furosemide and famotidine are the two medications that are used for the medical history and the EKG strip. The EKG strip show is rate controlled atrial fibrillation (a-fib). Furosemide is a loop diuretic, which lowers blood pressure by decreasing fluid

Fig. 3.1  Morning electrocardiogram (EKG) rhythm strip

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3  Items for the National Council Licensure Examination (NCLEX)

volume. This medication is used in CHF, hypertension, and a-fib. Acetaminophen is an antipyretic and analgesia. The medical history does not indicate pain or fever. Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) used for pain, fever, and inflammation. The medical history does not indicate inflammation. Isoniazid is an antituberculosis agent which kills bacteria that causes tuberculosis. Acyclovir is a nucleotide analog antiviral used to treat herpes simplex, varicella zoster, and herpes zoster. The medical history does not indicate a bacterial or viral infection. The level of Bloom’s taxonomy is application. A learner would need to know medications that are commonly used based on the medical history and also know the rhythm of the EKG strip represents. There are many distractors, but the learner also needs to know how the medications listed work and what is indicated for the client’s history.

3.3 Cloze (Drop-Down) Cloze items or drop-down options are a variation of completion items. In a cloze item, a sentence or whole passage is provided with keywords missing and options are provided for the learner to choose. In nursing, the cloze item is usually embedded in the statement of a multiple-choice item. See Table 3.2 for additional information. Table 3.2  Types of cloze items Drop-down cloze This question type has a statement that needs to use a drop-down menu for the word choices The word choices are more in number than the required answers needed in the statement

Drop-down table This question uses a table with the one side a body system or area and then the other drop-down menu of interventions or evaluations The statement should indicate one or more interventions in the drop-down menu

Drop-down rationale This question type uses a statement that provides an answer to what is occurring using two drop-down menus in the statement The statement should ask about completing the sentence by choosing from the options

3.3  Cloze (Drop-Down)

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Bloom’s Taxonomy This item type can address remember, understand, apply, and analyze levels of testing. More of these items are written to remember and understand level. Example Drop-Down Cloze A nurse is caring for a client who is coming to the clinic for a wellness visit. The client is 25 years old and cares for two biological children, ages 2 and 4 years. • Drag words from the choices to fill in the blanks. • The client is at risk for Stress, Stress, and Stress. • Word Choices Stress Infection Childcare issues Myocardial infarction Altered sleep patterns

Bloom’s Taxonomy: Apply Rationale: A client who is caring for young children may be at risk for stress, childcare issues, and altered sleep patterns. Caring for young children can impact a young adult’s social life and balancing the role of caregiver. The young adult is not at a greater risk for infection or myocardial infarction at this time. Drop-Down Rationale A nurse is caring for a client who is having difficulty breathing. The client has recently traveled to a foreign country. The current vital signs are the following: • • • • •

155/70 mmHg 100 beats per min 89% oxygen saturation 28 breaths per min 100.5 F by mouth

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3  Items for the National Council Licensure Examination (NCLEX)

Complete the following sentence by choosing from the options: The client is at the highest risk for developing Not started as evidenced by the client’s Not Started • Drop-Down 1 options: infection, stroke, pulmonary embolism, myocardial infarction. • Drop-Down 2 options: blood pressure, oxygen saturation, temperature, respiratory rate. Bloom’s Taxonomy: Apply Rationale: Based on the elevated temperature, the client is at risk for a respiratory infection. The blood pressure and heart rate are elevated and both of these can be related to the elevated temperature, as the body is working to stimulate an inflammatory response. Pearls and Pitfalls Similar to multiple-choice questions, a writer should make sure that the stem has ample amount of information, and each distractor is plausible. Avoid the use of terms from a textbook or from the teaching plan as an option listed in the answer. By doing this, learners memorize the answer, which lowers the Bloom’s taxonomy. More importantly, learners should understand the concept and be able to apply it to the situation presented in the item.

3.4 Drag and Drop (Ordering or Pick from a List) The drag and drop content type items allow learners to drag a piece of text or an image and drop it on one or more corresponding drop zones or lists. These types of questions can also be a list of procedural tasks that can be placed in order by the learner. Recently, the newer items can allow for three or four answers to be chosen from a list and moved into a drop zone. This type of

3.4  Drag and Drop (Ordering or Pick from a List)

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item is not new to nursing students but may be new to faculty developing this item type. Bloom’s Taxonomy This item type can address remember, understand, apply, and analyze levels of testing. Pearls and Pitfalls Similar to multiple-choice questions, a writer should make sure that the stem has ample amount of information, and each distractor is plausible. Examples Drag and Drop Ordering A nurse is preparing to administer insulin lispro 10  units subcutaneously to a client with a blood glucose of 265  mg/ dL. Please order the steps of the medication process in order, from the beginning to the administration of the insulin. Please order the nursing interventions in the column to the right. Scan the patient’s identification band Draw up the insulin Access the medication administration record Review medication order Teach the patient about the medication Review patient allergies

Bloom’s Level: Apply Rationale: Prior to administering any medication, there are certain steps a nurse must take. First, the nurse should access the medication administration record in the electronic health record. Next the nurse should review the order. Based on this situation, the nurse should validate that 10 units of lispro insulin is correct for the current blood sugar reading of 265  mg/dL.  Next the nurse should review the patient’s allergies, draw up the insulin and then teach the patient about the medication.

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3  Items for the National Council Licensure Examination (NCLEX)

Scoring, as mentioned earlier, should be addressed. Since there are six options, if the student mixes up one of the steps, maybe choosing to draw up the insulin before checking the patient’s allergies, the ± scoring would be in effect. Some educators use a scoring method that allows partial credit in the dichotomous mode. While some others would use the polytomous model. It depends on faculty understanding of which model is best for the student, the level of the student, and the organizational capabilities and software. Drag and Drop Pick from a List A nurse is caring for a client with congestive heart failure. Which nursing diagnosis are pertinent to the care of the client? Choose the top three nursing diagnoses for the client. Move them from the left column to the right column. Alteration in electrolytes Pain Fluid volume excess Ineffective breathing pattern Fatigue Impaired physical immobility

Bloom’s Taxonomy: Apply Rationale: The top three nursing diagnosis for a client with congestive heart failure is alteration in electrolytes, fluid volume excess, ineffective breathing pattern, and fatigue. A client with CHF has challenges with electrolytes specifically related to the use of diuretics to maintain the fluid balance. In addition, fluid overload or excess occurs when the client either consumes food high in sodium, which causes fluid retention and then overload. Due to respiratory issues and fluid challenges, a client will also experience ineffective breathing patterns and fatigue. The client with CHF does not have pain. The client may have activity intolerance instead of impaired physical immobility. If the four options are chosen, then the answer is correct. One nursing diagnosis does not supersede the other three. This item is similar to a SAA scoring. A nurse educator can score using the dichotomous or polytomous scoring.

3.6 Matrix/Grid

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3.5 Enhanced Hotspot (Highlighting) On this item type, learners are instructed to “click to highlight” answers pertinent to the question. This item type can be in a table format or a chart (which looks like an electronic health record) where the learner clicks on the areas to answer the question. This item type can be used in the case studies that are presented in the next chapter. If used for case studies, the text or table can be used with one of the six steps of the NCSBN Clinical Judgment Measurement Model (NCJMM), which uses clinical judgment and decision-making on the standardized examination. The steps in the NCJMM are to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. The examples below have the step assessed and Bloom’s taxonomy.

3.6 Matrix/Grid A matrix is presented in a table like format using either a MC or MR item. These item types are usually used in case studies. See the table for specifications of the matrix options. This item type can be used in the case studies, if used for case studies, the table can be used with MC or MC using one of the six steps of the NCSBN Clinical Judgment Measurement Model (NCJMM). Table  3.3 describes the difference in the Matrix multiple choice (MC) and multiple response (MR) item. Examples Matrix MC A nurse is caring for a client who is experiencing abdominal pain. The client stated that the pain starts 1–2 h after eating and lasts for 4 h. The pain is 9 out of 10 using a pain scale and remains the same for the 4 h. As a result, the client has a decreased appetite, which has also decreased to having a bowel movement every other day for the past 4 days.

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3  Items for the National Council Licensure Examination (NCLEX)

Table 3.3  Matrix types Matrix MC item 4–10 rows 2–3 columns Each row has one answer

Matrix MR item 4–7 rows 2–10 columns Each column has at least one response A row can have 0 to all answers

Match the assessment finding to the potential issues the client is experiencing. Each row has one answer. Assessment finding Nausea and vomiting Bloody diarrhea Jaundice

Bowel obstruction X

Ulcerative colitis

Liver cirrhosis

X X

NCJMM: Analyze cues Bloom’s Taxonomy: Apply Rationale: The case presents as a client with an abdominal concern. As a result, the assessment findings center on abdominal issues. Bowel obstruction may include severe abdominal pain, nausea, vomiting, and an inability to pass gas or stool. Ulcerative colitis symptoms may include rectal bleeding, bloody diarrhea, abdominal cramps, and pain. Liver cirrhosis initial presentation may have a client expressing fatigue, weakness, and weight loss. During later stages, the client may develop jaundice (yellowing of the skin), gastrointestinal bleeding, abdominal swelling, and confusion. Matrix MR A nurse is caring for a 75-year-old client who is admitted to the medical surgical unit for a fever (temperature of 101.1  F by mouth) of unknown cause. Current VS: blood pressure 145/78 mmHg, 96 beats per min, 24 respiratory rate/min, pulse oximetry of 95%. The admitting orders required the nurse to start peripheral intravenous access with 0.9% normal saline at 100 cc/

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3.7  Additional Types

hr., draw laboratory assessments (CBC) and blood, urine, and sputum cultures prior to administering a broad-spectrum antibiotic. The nurse administers acetaminophen 1000 mg PO. Match the assessment finding based on the case study Assessment finding Temperature of 99.9 F by mouth RR 22 BP 140/78 Pulse oximetry of 97% Pain rating of 0 out of 10 on scale from 0 to 10, with 10 being the worst pain Asks to go the bathroom with assistance

No Improved change X X X X X

No relevant

X

NCJMM: Prioritize Hypothesis Rationale: Based on the assessment findings, the temperature and asking to use the bathroom are improved. The temperature is decreased based on the decrease in temperature from 101.1 to 99.9. The other vital signs are very similar to those in the case presentation. Asking to use the bathroom is not pertinent to the case as no information was presented to indicate the client was having confusion or was oriented to person, place, and time.

3.7 Additional Types Currently, the NCSBN’s website has a tutorial for NCLEX for the different item types (NCSBN, n.d.). The following items are listed: MC, MR, fill in the Blank, Exhibit, Drag and Drop/Ordered Response, and Graphic. Further explanation is added. A calculator is also provided in the tutorial. Fill in the Blank Learners will enter a response, rather than choose from a list of predetermined answer choices. A sentence is presented with key components necessary to complete the fill in the blank. For a computerized exam, the learner will enter using the keypad.

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Exhibit Item Learners will be exposed to a prose of writing which requires them to click on a tab labeled “Exhibit.” Here an additional ­window will appear, and the learner can use the information to answer the question. If they close the window, they can reopen the “Exhibit” by clicking on the tab again. The “Exhibit” window can be moved around the screen to allow for viewing of the question and the additional information. Drag and Drop/Ordered Response Learners will be exposed to the use of dragging and dropping options into the correct order. In this example, there were two columns. The learner needed to move the items from the left unordered side to the right ordered side. The information presented indicated that all the options needed to be used. This item is similar to the ones presented earlier. Graphic Item Learners will be able to use a graphic instead of text to choose the correct response. The item has a stem and question. But all possible answers are graphics. Summary Most items, even written by experienced item writers, should be reviewed extensively prior to administration. Asking a colleague to review is helpful and insightful. Item writers, especially nurse educators, should be encouraged to write their own items, reflect on them, and revise, as necessary. As mentioned, items for examinations should assess appropriate and important information.

Reference NCSBN. (n.d.). NCLEX Item Types Tutorial. https://abe-­prd-­1.pvue2.com/ st1/driver/startDelivery?sessionUUID=610c5236-­9 df7-­4 09a-­8 24b-­ 4c706270a052

4

Case Study Development

Abstract

Writing case studies is not new to nurse educators. Including details is necessary for case study development. This chapter will address the guidelines to make a successful case study with the infusion of the National Council State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (NCJMM) steps. Keywords

Case study · Case study items · NCJMM

Learning Objectives 1. Explain the elements necessary is a case study buildout. 2. Describe item types used in case studies. 3. Explain the NCJMM model and the steps involved in case study development.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­30211-­4_4.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_4

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4.1 Case Study Case studies are clinical nursing scenarios. Case studies are typically longer in length than other item types and should be as realistic as possible. They are in-depth, detailed examinations of a real-world case. For nursing, the case study should ask questions relevant to the nursing process which guides nursing practice: assessment, diagnosis, planning, implementation, and evaluation. There are really no set requirements for case study development. As stated in learning objectives, learners should be tested on items that have a learning objective. Therefore, the learning objective should drive the case study. If the learning objective was related to diabetes management of insulin requirements for a client diagnosed with type 1 diabetes, then the focus would be on writing a case based on a realistic client. The case may start with a client being seen by a clinic or emergency department and then eventually is hospitalized. Insulin management should be ordered, and the client taught about how the medication works including special considerations and adverse effects associated with insulin administration. Ideally, the case should have nurses’ notes, laboratory assessments, and vital signs. Tabs are often used in case studies development. If the computer software is able to create tabs similar to an electronic health record, the case looks more realistic. It is important to note that in an evolving case study, the times and dates should be sequential and presented in a manner that reflects the notes or vitals over time. If the exam software does not allow for tabs, this can easily be managed by creating a word document with the information and handing it out during class time for practice questions or during an exam to test items. See Fig. 4.1. The template at the end of the chapter can be used to provide some guidance on building out a case study. This template can be repeated to achieve all the steps required for the NCJJM. One important note to understand when developing case studies for nursing education. Is that case studies should be introduced early in a nursing curriculum and the questions related

4.1  Case Study

NURSES NOTES

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H+P

VITALS

LABS

EXAMPLE Fig. 4.1  Electronic health record Table 4.1  Case study elements Patho­ Condition physiology Diabetes T1D—insulin deficiency T2D—insulin resilience

Medications T1D—short acting/long acting T2D—oral medications

Labs BG A1C Pre5.5– 6.4

Nursing care BG before meals Screening for depression, anxiety, and diabulimia

Patient education Teach about diet, exercise, medications Teach about long- and short-term complications

to the case study should be at the appropriate level of the learner. Early learners in professional development should have Bloom’s taxonomy levels of remember and understand with small items to apply. However, when using case studies in learners preparing for either the NCSBN exam or for certification, the use of the apply and analyze items is highly recommended. In addition, the use of the alternate form items presented in Chap. 3 is appropriate for higher level learners. Below is Table  4.1 to determine some of the elements in developing a case study.

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4.2 Case Study Items for Nursing Education and NCJMM Nursing has witnessed an increase in patient acuity and infusion of new technology impacting nursing expectations in the healthcare environment. Safety standards, related to patient care, are also driving the increased expectation in the healthcare settings. Most new nurses, many with less than 6 months of practice, are engaged not only in critical patient care decisions, but are also engaged with leading a team of nurses each shift and educating new nursing graduates and nursing students. As a result, nursing curriculums need to prepare students for the many facets of the evolving healthcare environment. Prior to 1990, each state created and administered their own nursing examination. Since the early 1990s, NCSBN has been in charge of the licensure exam for both registered and practical nursing. In 1994, the first computerized adaptive national licensure exam was administered as the National Licensure Examination for Registered Nurses (NCLEX-RN). In 2015, NCLEX was adopted in Canada, resulting in changes to address measuring units, use of generic drug names, and other terminology differences between the United States and Canada. Every 3  years, the NCSBN administers a survey to nursing students, nurse educators, and nurse leaders in practice environments to address the knowledge, skills, and activities necessary for nursing practice. The survey supports the content on the NCLEX blueprint. All of these publications, including national first-time pass rates, can be found at https://www.ncsbn.org/. The nursing process, necessary for the profession, is a solid tool for clinical judgment in novice nursing students but lacks the integration of complexity necessary for the advanced new graduate nurse (Tanner, 2006). The theories behind the development of the National Council Judgment Measurement Model (NCJMM) have been used by nursing educators to prepare students for their professional role as registered nurses. NCJMM has leveraged and merged the theories into a model applicable to observational, cognitive operations, and environmental factors (Dickison et  al.,

4.2  NCJMM and Test Items for Nursing Education

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2016). The NCJMM is a method for measuring and deriving valid inferences around the nursing clinical judgment and decision-­ making ability of prospective entry-level nurses (Dickinson et al., 2019; Dickinson et al., 2020; NCSBN, n.d.-a, n.d.-b). There are six layers of the NCJMM in Fig. 4.1. It is important to recognize the arrows that are present in all the layers that go from one layer to another. Layer 0, the broadest category, includes client needs and clinical decisions. Layer 1 is the clinical j­ udgment level. Layer 2 contains the hypothesis that is formed, defined, and evaluated. Layer 3 contains the most elements used in the model. Layer 3 outlines the cognitive aspects of clinical decision-­making that are directly measurable and are the basis for the development of Next Generation NCLEX test items and case studies for the NCLEX exam (NCSBN, n.d.-a, n.d.-b). Most of the questions used in the unfolding case studies are from Layer 3 (Fig. 4.2). The NCSBN Clinical Judgment Measurement Model Client Needs

Clinical Decisions

Layer 0 Clinical Judgment Layer 1

Satisfied Not Satisfied Refine Hypotheses

Form Hypotheses

Evaluation

Layer 2 Recognize Cues

Analyze Cues

Prioritize Hypotheses

Generate Solutions

Evaluate Outcomes

Take Actions

Layer 3 Environmental Factor Examples

Individual Factor Examples

Environment

Client Observation

Resources

Medical Records

Knowledge

Skills

Specialty

Consequences & Risks

Time Pressure

Task Complexity

Cultural Consideration

Candiadate Characteristics

Prior Experience

Level of Experience

Layer 4

Nursing Process

Assessment

Analysis

Planning

Copyright ©2019 NCSBN. All Rights Reserved.

Fig. 4.2  NCSBN CJMM (NCSBN, n.d.-a , n.d.-b)

Implementation

Evaluation

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4.2.1 Relationships of Layer 3 and Items for Case Studies In Layer 3, there are 6 steps to the NCJMM.  They are used to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate options. In the case studies, each question should be based on one of the six steps (Table 4.2). Table 4.2  Steps of NCJMM and item types Step 1. Recognize cues

2. Analyze cues

3. Prioritize hypotheses

Possible item types to use Multiple choice Highlight item text Highlight item table Multiple choice Drag and drop—close Drag and drop—rationale Matrix multiple response Matrix multiple choice Multiple response—select all that apply Multiple response—grouping Multiple response—select a certain number Multiple choice Drag and drop—close Drag and drop—rationale Matrix multiple response Matrix multiple choice Multiple response—select all that apply Multiple response—grouping Multiple response—select a certain number

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4.3  Stand-Alone Items Table 4.2 (continued) Step 4. Generate solutions

5. Take action

6. Evaluate options

Possible item types to use Multiple choice Drag and drop—close Drag and drop—rationale Matrix multiple response Matrix multiple choice Multiple response—select all that apply Multiple response—grouping Multiple response—select a certain number Multiple choice Drag and drop—close Drag and drop—rationale Matrix multiple response Matrix multiple choice Multiple response—select all that apply Multiple response—grouping Multiple response—select a certain number Multiple choice Drag and drop—close Drag and drop—rationale Matrix multiple response Matrix multiple choice Multiple response—select all that apply Multiple response—grouping Multiple response—select a certain number

A variety of item types, as presented in Chap. 3, can be used in the steps. Importantly, multiple-choice items can also be used in each of the steps. An example of an unfolding case study is at the end of the chapter.

4.3 Stand-Alone Items A stand-alone item targets one or more of the clinical judgment functions in Layer 3 and Layer 4 of the NCJMM. There are two stand-alone items: Bowtie and Trend item.

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4.3.1 Bowtie Uses all six steps of Layer 3. There is lead in information for the learner to read. “The entry-level nurse has to read the scenario on the left to recognize if findings are normal or abnormal (Recognize Cues), understand the possible complications or medical conditions the client may be experiencing (Analyze Cues) and identify possible solutions to address the client’s needs and issues (Generate Solutions). The entry-level nurse will then answer the bow-tie item on the right to determine the most likely cause of the client’s issues (Prioritize Hypotheses), the appropriate actions to take (Take Action) and the parameters to monitor once interventions have been implemented (Evaluate Outcomes). This is why it is called a ‘bow-tie’ item because the response area looks like a bowtie with two “Actions to Take” on the left, two “Parameters to Monitor” on the right and a single “Potential Condition” response in the middle (NCSBN, 2021). See the example of the Bowtie at the end of the chapter.

4.3.2 Trend Item Trend items address multiple steps of Layer 3 of the NCJMM, but do not follow the six-item sequence like case studies do (NCSBN, 2021). There can be one or more steps in the trend item, but it does not use all six steps. Trend items can feature any item response type. Possible tabs include Nurses’ Notes, History and Physical, Laboratory Results, Vital Signs, Admission Notes, Intake and Output, Progress Notes, Medications, Diagnostic Results, and Flow Sheet (NCSB, 2021). Examples Case Study—submitted as additional file “Chap. 4 Case Study” Bow-Tie—submitted as additional file “Chap. 4 Bow Tie” Trend Item—submitted as additional file “Chap. 4 Trend Item”

References

53

Summary Case study development is imperative to assess a learner’s clinical judgment. As nurse educators, the clinical setting provides an excellent opportunity to gather information to develop a case. Focus on the learning objectives and steps to assist in the development of the case.

References Dickison, P., Lou, X., Kim, D., Woo, A., Muntean, W., & Bergstrom, B. (2016). Assessing higher-order cognitive constructs by using an information-­processing framework. Journal of Applied Testing Technology, 17, 1–19. Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the national council of state boards of nursing clinical judgment model into nursing educational frameworks. The Journal of nursing education, 58(2), 72–78. https://doi.org/10.3928/01484834-­20190122-­03 Dickison, P., Haerling, K.  A., & Lasater, K. (2020). NCSBN Clinical Judgment Measurement Model Clarification. The Journal of nursing education, 59(7), 365. https://doi.org/10.3928/01484834-­20200617-­02 NCSBN. (n.d.-a). https://ncsbn.org/exams/next-­generation-­nclex/ NGN+Resources/clinical-­judgment-­measurement-­model.page NCSBN. (n.d.-b). NCSBN NCJMM. https://ncsbn.org/clinical-­judgment-­ measurement-­model NCSBN. (2021). Next Generation NCLEX NEWS: Stand-alone Items. https://www.ncsbn.org/public-­files/NGN_Spring21_Eng.pdf Tanner, C.  A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45, 204–202.

5

Item and Exam Analysis

Abstract

Writing items for evaluation of essential nursing knowledge and constructing exams are important to nurse educators. Item analysis uses the actual responses of individual people to individual test items to provide information regarding the items. This chapter will address common themes to assist in evaluating both items and exams. Keywords

Item analysis · Exam evaluation · Exam reliability

Learning Objectives 1. Describe correct assessment of item analysis 2. Describe the techniques used to evaluate an exam

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_5

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5.1 Item Analysis Item analysis provides information about difficulty, discrimination, and differential item functioning (DIF). 1. Difficulty is determined by the learners. If all the learners answer an item correctly, then the difficulty is low. Knowing the difficulty of items allows educators to make sure an exam is not too difficult or too easy. A p value is used to assess a very easy or very difficult item. It is a function of the number of learners who knew the answer plus the number of learners who were able to correctly guess the answer. If out of 100 learners, 72 of them answered correctly, the p value is 0.72. Higher values denote easier items (more learners answered the item correctly), and the lower values denote harder items (fewer learners answered the item correctly). Difficulty index with p value 0.80 are easy, with a range of 0.3–0.7 as desirable for norm-referenced tests (Oermann & Gaberson, 2021). 2. Discrimination is the ability of a learner to answer the item correctly based on knowledge learned. This concept indicates the extent to which an item corresponds to success on the whole test. It also describes the ability of an item to differentiate among learners who performed more successfully than the weaker learners. Discrimination index ranges from −1 to +1 with positive numbers over 0.2 reliably implying that an item is discriminating (Downing & Haladyna, 2006). Discrimination indices often use the high/low ranges, those that performed higher compared to lower on the exam item. This is often referred to as point biserial correlations. In discriminating items, there is no such thing as a perfect item. The general guidelines are listed in Table 5.1. A nurse educator should consider essential knowledge when evaluating items as discriminating. Items that are essential, such as alterations of vital signs related to a disease process or washing

5.1  Item Analysis

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Table 5.1  Discrimination index for correct and incorrect answers Correct answer

Distractors

Negative discrimination Could be a miskeyed or misleading Not discriminating Consider revising Discriminating Consider some revising Strongly discriminating Should be evaluated using the same scale Negative discrimination (i.e., −0.4 or −0.02) Weaker students choose this answer Not discriminating Consider revising Discriminating Consider some revising Some of the stronger students choose this response Strongly discriminating

hands, can have a slightly negative index such as −0.1. Knowledge that is essential should not cause an alarm or signal an issue with the item. Discrimination should not be a stand-alone value. Distractors should also be evaluated with the discrimination index. In addition, discrimination can take into effect dichotomous items and is used to recognize learners who performed more successfully than the weaker learners.

5.1.1 Point Biserial Correlation Coefficient (Point Biserial Index [BPI]) As mentioned earlier, this statistic is interpreted in the same manner as the discrimination index. It measures a learners’ response to an item and his or her overall performance on the exam (Oermann & Gaberson, 2021). Values range from −1.00 to +1.00 with higher values related to those students who answered the item correctly and the lower values whose overall test performance was poor.

5  Item and Exam Analysis

58 Table 5.2  Point biserial index 95% difficulty) and harder items (50–60% difficulty). Too many easier or harder items can either increase or decrease the KR. The higher the variability in scores, the higher the reliability of the exam (McGahee & Ball, 2009).

5  Item and Exam Analysis

62 Table 5.3  Reliability estimates Cronbach’s alpha Continuous variables and non-­dichotomous data Partial credit

Likert scales

Kuder Richardson formula (KR) Dichotomous data (right and wrong) KR 20 Dichotomous data Portion of correct response Standard deviation of the total score KR 21 Dichotomous data Portion of correct responses Mean of total score Standard deviation of the total score Lower estimate of reliability

5.3 Scoring and Answer Changing Scoring is a relatively new element in the NCSBN blueprint and will go live April 1, 2023. The model will change from “all correct” or “all incorrect,” a dichotomous model, to a polytomous model. These models will allow partial scores of items with multiple points (NCSBN, n.d.). Since this will change the scoring, nurse educators should prepare to introduce this scoring model to learners preparing for the NCLEX-RN exam. Early introduction to this model in the nursing curriculum with guidelines on how to prepare and answer these questions is essential. Throughout the curriculum, if the capability exists, the scoring method should be introduced. Answer changing behavior has recently been examined by nurse educators. Nurse educators have a long history of thinking that students should not go back and change answers (Blakeman & Laskowski, 2020). Many faculty teach students to not change their answers after they have chosen an answer. However, a recent study determined that students benefited from changing their answers using exam software (Bultas et al., 2021). Nurse educators should be teaching content and reviewing questions with learners so that they are better prepared for exams. Nurse educators should use evidence-based teaching practices. Specifically, nurse educators should develop learning objectives

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and teach relevant nursing content. A strong nurse educator should provide sample items for the students to practice knowledge attainment and assess if students are understanding the material presented. A nurse educator should be guiding the students how to answer the sample items either in the classroom or during clinical time.

5.4 Other Considerations for Items and Exam Construction Earlier in the chapter item difficulty and discrimination was examined on items on an exam. There are a variety of other factors that influence the reliability of items on the exam. Therefore, consistency is an important factor that should be considered and accounted for while creating and administering exam items. • Item selection –– Choose items relating to the learning objectives and the content covered • Test length –– There is no set number of questions but 40–60 items are typically used in nursing exams –– Allow one minute per question • Group homogeneity—how similar the items perform on other groups of learners • Test–retest interval –– Shorter time interval between two administrations of a test, the higher the reliability –– This may assist with repeat examinations or final examinations after review of content • Variation with the testing situation –– There can also be learner factors that should be addressed such as misreading test direction, noise level, distractions, and sickness that can cause test score variation

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Summary Nurse educators need to thoroughly understand the process of item and exam analysis. By engaging in these behaviors, a nurse educator can benefit from valid nursing examinations with usability in nursing pre-professional and professional development.

References Blakeman, J. R., & Laskowski, P. S. (2020). Beliefs and experiences of nurse educators regarding changing answers on examinations. Nursing Education Perspectives, 41(2), 97–102. https://doi.org/10.1097/01. NEP.0000000000000497 Bultas, M.  W., Schmuke, A.  D., Rubbelke, C., Jackson, J., & Moran, V. (2021). Assessment of answer-changing behavior of nursing students and faculty recommendations. Journal of Nursing Education, 60(6), 324–328. Downing, S. M., & Haladyna, T. M. (Eds.). (2006). Handbook of test development. Lawrence Erlbaum Associates Publishers. McGahee, T. W., & Ball, J. (2009). How to read and really use an item analysis. Nurse Educator, 34(4), 166–171. https://doi.org/10.1097/ NNE.0b013e3181aaba94 NCSBN. (n.d.). https://www.ncsbn.org/exams/next-­generation-­nclex/ NGN+FAQS/ngn-­faqs-­for-­educators.page. Oermann, M. H., & Gaberson, K. B. (2021). Evaluation and testing in nursing education (6th ed.). Springer. Woo, A., & Dragan, M. (2012). Ensuring validity of NCLEX® with differential item functioning analysis. Journal of Nursing Regulation, 2(4), 29–31.

6

Mapping

Abstract

The purpose of this chapter is to map exam items to core curricular elements. As mentioned earlier, objectives provide a roadmap for learning. Accrediting bodies ensure that the nursing graduate or professional is continuing to develop in knowledge, skills, and attitudes. Therefore, mapping exam items support the development of nursing professionals and provide a thorough vision of the nursing curriculum, from entry to graduation. Keywords

Evaluation · Mapping · Integrative process

Learning Objectives 1. Examine different methods to map exam items. 2. Utilize exam items to address knowledge gaps.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Moran, Item Writing for Nurse Educators, https://doi.org/10.1007/978-3-031-30211-4_6

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6.1 Evaluation Introduction Evaluation is a term that describes the process of examining the value, worth, or quality of nursing curriculums. Evaluation uses judgment to determine what has been learned by the learners. In nursing education, there are many ways to evaluate educational attainment. Faculty evaluate students’ knowledge, skills, and attitude attainment in the cognitive, psychomotor, and affective domain in both the clinical and didactic setting. Faculty evaluate teaching and effectiveness. Administration evaluates the outcomes of the curriculum, in light of student progression and graduation. There are a variety of reasons to evaluate: to facilitate learning, diagnose problems, make decisions, improve processes or projects, judge effectiveness and cost effectiveness (Billings & Halstead, 2019). Part of the evaluation process requires assessment of the pre-licensure expectations and quality of performance with an emphasis on evidence about current learning practices. The evidence is generated from clinical and classroom observations incorporating quantitative and qualitative measures including exam items. The process of evaluation is a nurse faculty teaching responsibility. From objectives through item exams, nurse educators are responsible for demonstrating knowledge attainment through items written for nursing examinations.

6.2 Mapping Exam Items to Course Objectives (COs) or Learning Outcomes (LOs) Course objectives and learning outcomes, otherwise known as achievable outcomes, are leveled according to the program year or semester of the student and from the end-of-program objectives. CO/LOs should be written at the appropriate level of the student (Billings & Halstead, 2019). In nursing education, the syllabus is responsible for documenting the COs. The syllabus should also contain the course descrip-

6.3  Mapping Exams to Student Learning Outcomes (SLOs)

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tion, the objectives being evaluated, evaluation methods, course grading scale, course expectations, and university/college policies. Depending on the course, an exam item can be mapped to a specific CO. For example, if there are two pharmacology courses, it is imperative that each pharmacology course is mapped to specific COs. Exam items can then be marked for each of the different courses. Course evaluations should be completed at the end of each semester. The course evaluations, completed by faculty who taught in the course, should demonstrate what has been learned, how the learning occurred, and how the COs were evaluated. This should also occur with nurses developing continuing education for hospital or clinic nurses. An evaluation should occur annually so that there is a process improvement cycle occurring. Items that were used to evaluate the COs should be included in the evaluation process.

6.3 Mapping Exams to Student Learning Outcomes (SLOs) Two accrediting bodies for nursing, the American Association of Colleges of Nursing (AACN) and National League for Nursing (NLN), require nursing education to achieve student learning outcomes (SLOs). Development of nursing SLOs typically come from a variety of sources including nurse educators and administrators following the higher education organization mission and vision. SLOs are broader outcomes and typically represent the outcomes of what a nursing graduate from a particular university/ college demonstrates as professional values and behaviors. There may be specific roles and responsibilities, but they are described as an overarching outcome. Exam items should be mapped to SLOs. Some nursing courses may struggle with finding a SLO for each exam item. However, a course evaluation at the end of each semester or term should map

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exam items and this will benefit the accreditation process. By mapping, nursing faculty can examine deficiencies in the curriculum as a whole.

6.4 Mapping Exam Items to NCLEX Blueprint The NCLEX blueprint has client need categories. Table 6.1 identifies the breakdown of the client categories effective April 1, 2023. (NCSBN, n.d.) In addition to nursing knowledge, there are integrative processes that are imperative to nursing practice. The definition of clinical judgment is new to the April 2023 blueprint. NCSBN has definitions of each of the integrated processes. See Table 6.2. The breakdown of the six steps of the clinical judgment is also included in the April 2023 NCSBN blueprint. This information was presented in Chap. 4 in development of case studies. One important aspect for understanding the NCLEX blueprint is mapTable 6.1  NCLEX client need categories Client needs Safe and effective care environment    Management of care    Safety and infection control Health promotion and maintenance Psychosocial integrity Physiological integrity    Basic care and comfort    Pharmacological and parenteral therapies    Reduction of risk potential    Physiological adaptation

Percentage of items from each category 15–21% 10–16% 6–12% 6–12% 6–12% 13–19% 9–15% 11–17%

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Table 6.2  Integrated processes Caring

Interaction of the nurse and client in an atmosphere of mutual respect and trust. In this collaborative environment, the nurse provides encouragement, hope, support, and compassion to help achieve desired outcomes Clinical judgment The observed outcome of critical thinking and decision-making. It is an iterative process with multiple steps that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care Communication Verbal and nonverbal interactions between the nurse and and the client, the client’s significant others and the documentation other members of the health care team. Events and activities associated with client care are recorded in written and/or electronic records that demonstrate adherence to the standards of practice and accountability in the provision of care Culture and Interaction of the nurse and the client (individual, spirituality family, or group, including significant others and populations) that recognizes and considers the client-reported, self-identified, unique, and individual preferences to client care, the applicable standard of care, and legal considerations Nursing process A scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation, and evaluation Teaching/learning Facilitation of the acquisition of knowledge, skills, and abilities promoting a change in behavior (NCSBN, n.d., p. 4).

ping exam items to the client need categories and the subcategories. Mapping exam items to those categories can assist in the evaluative process. The mapping should be analyzed annually to identify any deficiencies.

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Summary Item writing is part of the evaluation process. By tagging exam items to COs, SLOs, and/or NCLEX blueprint, the documentation will provide a thorough understanding of how well the learners and nursing faculty are teaching and validate a program’s areas of strengths and weaknesses.

References Billings, D.  M., & Halstead, J.  A. (2019). Teaching in nursing e-book: A guide for faculty. Elsevier. NCSBN. (n.d.). Next Generation NCLEX: NCLEX-RN® Test Plan Effective April 2023. https://www.ncsbn.org/public-­files/2023_RN_Test%20Plan_ English_FINAL.pdf