Just what is the CJE Build-Your-Own Question Bank for Next Generation NCLEX®? Healthcare is more dynamic than ever, with nurses providing care in the face of unprecedented challenges and constantly developing tech solutions. To ensure public safety and successful careers in nursing, an increased focus on clinical judgment is crucial.
What are Clinical Judgment Exams (CJE)?In anticipation of the Next Generation NCLEX®, NurseThink® and ExamSoft partnered to create Clinical Judgment Exams (CJE). CJE provides pre-written, high-quality assessments to improve nursing education and better prepare students for both the exam and clinical practice.
A critical feature of CJE is the Build-Your-Own Question Bank, which allows nurse educators and exam administrators to build formative and summative assessments using questions written by experts in nursing education and experienced clinicians at NurseThink®. The Build-Your-Own Question Bank gives nurse educators the option to add prewritten questions to their own assessments or create assessments consisting completely of the questions provided by ExamSoft and NurseThink®. The purpose of CJE is to ensure students preparing to be nurses have the skills and readiness to practice in the field, beyond what they can execute in the classroom at a desk. This may include topics such as bedside manner, handling crises, reading electronic health records, and more training.
What is clinical judgment?The National Council of State Boards of Nursing defines clinical judgment as “an iterative process 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.”
There are many interpretations of this definition.
The American Association of Colleges of Nursing expands on the definition, stating its impact on care outcomes:
“As one of the key attributes of professional nursing, clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning. This process is used to understand and interpret information in the delivery of care. Clinical decision making based on clinical judgment is directly related to care outcomes.”
Benner and Tanner, leading researchers in the field of nursing and authorities on clinical judgment, illustrate clinical judgment as “the ways in which nurses come to understand the problems, issues, or concerns of clients and patients, to attend to salient information, and to respond in concerned and involved ways” (Benner & Tanner, 1997, p. 200).
Clinical judgment is the process with which nurses decide on patient data collection, interpretation of that data towards a nursing diagnosis, and finally identifies nursing actions based on data. This is a complex process that involves problem solving, decision making, and critical thinking.
In short, clinical judgment is the way a nurse enacts knowledge.
Because clinical judgment impacts patient care outcomes and because it is a critical component of effective nursing, evaluating clinical judgment is an important part of qualification.
In recent years, the NCSBN identified opportunities to enhance the NCLEX® to more effectively test clinical judgment and prepare new nurses to provide the best patient care. The NCSBN decided to create a new version of the test— the new and improved Next Gen NCLEX® includes new question types and an increased focus on clinical judgment. For instance, these new questions will highlight case-based scenarios in order to evaluate clinical decision making.
The American Association of Colleges of Nursing outright states, “Clinical decision making based on clinical judgment is directly related to care outcomes.”
Almost half of all nursing tasks involve making clinical decisions. According to research, critical care nurses often make decisions—exercising clinical judgment—every thirty seconds (Bucknall, 2000).
Clinical judgment can affect whether or not patients feel their expectations were met. Patient satisfaction—a measure of how happy a patient is with their healthcare—is an important and common proxy to measure the success of doctors and facilities. It is also used as an indicator of the quality of care overall.
Just as with quality care, patient satisfaction leads to better clinical outcomes, patient loyalty and retention, patient compliance, and fewer medical malpractice suits.
In research regarding patient satisfaction with their ER experience, many factors were mentioned, and none involved clinical ability. Physician and nurse courtesy, waiting room comfort, waiting time, information about their diagnosis and prognosis, cleanliness, and satisfactory pain control were highlighted.
In Muntlin’s 2006 study, “Patients estimated quality of care at the emergency department as fairly good, but there were areas in need of improvement. A high percent of inadequate quality was related to the environment in the emergency department. About 20% of patients reported that they did not receive effective pain relief. More than 20% estimated that nurses did not show an interest in their life situation and patients did not receive useful information on self-care and about which physician was responsible for their medical care” (Muntlin, et. al., 2006).
Muntlin goes on to conclude, “Many of the identified areas for quality improvement are related to nursing care. Therefore, the importance of nursing care in the emergency department should be highlighted to nurses and physicians and they also need to be more attentive to the need [sic] of the individual patient” (Muntlin, et. al., 2006).
Medical skill is rarely mentioned, if at all, as a component of patient satisfaction.
What did count toward patient satisfaction was effects of clinical judgment; communication about their diagnosis, bedside manner, and appropriate medication for pain rated highly.
What good is your knowledge, patients seem to say, unless I know how much you care?
What are the reasoning steps of clinical judgment?The Next Generation NCLEX® is based on the NCBSBN Clinical Judgment Measurement Model, which is in turn informed by Chris Tanner’s model of clinical judgment and four reasoning steps:
- Noticing: What is expected in a clinical situation; what should be done first, and what additional information is needed?
- Interpreting: What does the data mean?
- Responding: What are possible next steps and interventions?
- Reflecting: What can be done next time? What improvements can be made? (Tanner, 2006).
According to Tanner in Thinking like a nurse: a research-based model of clinical judgment in nursing, “A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.” Providing examples of clinical judgment and real-life application to students, too, helps students engage in these steps.
Clinical reasoning and clinical judgment are sometimes used interchangeably. But clinical judgment does not exist without clinical reasoning. Because clinical judgment is about how a nurse enacts data, it is an outcome or result of a nurse’s critical thinking and critical reasoning.
Clinical judgment can therefore be framed in the following way:
Keith Rischer differentiates these components as independent but interrelated steps to develop clinical judgment.
- “Critical Thinking requires the nurse to think clearly, precisely, and accurately and act on what they know and UNDERSTAND and are able to apply to the bedside…not memorize to pass the test.
- Clinical Reasoning is the thinking in action that takes place at the BEDSIDE while providing patient care and is dependent on the ability of the nurse to apply knowledge, and reason as a situation changes over time.
- Clinical Judgment is the nurse’s conclusion that recognizes then correctly interprets relevant clinical data to determine the best response for the patient” (Rischer, n.d.).
Clinical judgment can be the result of a process; when the nurse takes the extra step of reflecting on their clinical judgment, it then becomes part of an ongoing process and feedback loop.
The development of clinical judgment leads to appropriate nursing diagnoses, clinical decision-making, and health promotion (Seidi, et. al., 2015). It is, without doubt, an important part of effective nursing.
Clinical judgment, while not new, is a novel movement within nursing education and currently replacing the nursing process. According to Ignatavicius and Silvestri, “Clinical judgment is more closely aligned with how nurses in practice actually think to make the best possible decisions about client care.”
They provide the following diagram, emphasizing, “While these models may look very similar, the thinking processes differ. For example, in the Assessment step of the nursing process, the nurse collects subjective and objective client data using a systematic approach. By contrast, the Recognize Cues cognitive skill of clinical judgement [sic] requires the nurse to collect client data and then decide “What matters most?”—which client data (findings) are relevant in a specific contextual clinical situation and which data are not relevant?”
Clinical judgment can be nurtured in nursing students by supporting the development of critical thinking and clinical reasoning (Rischer, n.d.).
First off, do students really understand the information they are taught? According to Dylan Wiliam, assessment is the bridge between teaching and learning and a critical intersection for measuring whether or not students understand what has been taught. Appropriate reliable and valid assessments are critical to supporting the nurse’s learning journey and ensure that they have a deep understanding of essential knowledge.
As with all instruction, it’s important to help students understand why what they are learning is important and how to apply it to real-life scenarios. They may have aced microbiology, but how and when does it apply to infection control? And how do they communicate this care to patients? They must apply their knowledge to real-world scenarios and practice clinical reasoning frequently and in low-stakes environments. An authentic learning approach makes course concepts relevant to students so that they can retain the information at hand and pivot the knowledge to real-world situations.
Researchers validate the need for this authentic learning, stating, “Simulation-based education and clinical placement are the learning activities in nurse education most relevant to facilitating the development of students’ clinical judgment. Failure for students to receive educational support and thereby achieve an adequate level of clinical judgment constitutes a major threat to patient safety, potentially leading to negative consequences for patients and society” (Høegh-Larson, et al., 2023).
Finally, it is important to model the reasoning steps of clinical judgment itself and provide space for reflection. What went well and what did not go so well? This is a critical junction that can help students learn from any past mistakes or help others vent their frustrations while receiving feedback and guidance from instructors. Reflection also bolsters resilience.
By placing nursing students in safe spaces for failure, like simulations or low-stakes clinical environments, instructors can provide opportunities for students to develop clinical judgment. According to Manu Kapur, known as the father of the theory of productive failure, “The goal is to design experiences that incorporate failure in a safe, curated way. Then, we turn that initial failure into something that is productive by stepping in, giving students feedback and guidance, and helping them to make sense of the material by assembling it into a more coherent whole” (Terada, 2022).
How can clinical judgment be measured?According to research, clinical judgment is “a challenging concept to articulate and assess,” adding, “Clearly identified characteristics could provide a framework for clinical judgment to assist both clinical nurses and nurse researchers in observing and describing clinical judgment in action” (Jacobs, et al. 2018). Providing a framework and rubrics are the first steps towards reliable and valid measurement of clinical judgment.
To that end, Clinical Judgment Exams prepare nursing students for evaluation.
How are nurse educators using the Build-Your-Own Question Bank?Nurse educators use the CJE Build-Your-Own Question Bank for both summative and formative assessments.
After building a formative assessment, instructors administer these quizzes to check in with students on their progress. Often called “muddy points” quizzes, these are ungraded and can be taken in small teams. Instructors may give these quizzes at the beginning of class to assess the knowledge students gained from the reading, which gives the instructor an idea of where they should focus their teaching for the day.
Instructors may also give these quizzes at the end of a class period to gain an understanding of what students understood from the day’s lecture and what content areas could use additional attention. Consider them a check-up, if you will.
At the end of a unit or semester, instructors may create a summative assessment with CJE questions that cover the content and/or skills taught during that time period. Like the formative assessments, the summative exams give students more practice with clinical judgment questions and new item types, all while familiarizing students with the kind of digital testing environment they’ll encounter during the Next Generation NCLEX®.
How does the CJE Build-Your-Own Question Bank help nurse educators?When the NCSBN announced the Next Generation NCLEX®, many nurse educators realized that they were going to have to write new questions to prepare their students for the exam. With the CJE Build-Your-Own Question Bank, powered exclusively by ExamSoft, nurse educators gain access to expertly developed questions, centrally stored within the ExamSoft platform, so they can spend less time creating exams and devote more time to teaching.
With auto-grading, exam results are available almost immediately, and educators gain instant access to automated reports that reveal performance trends for the course, as well as individual students.
Each specialty Build-Your-Own Question Bank includes Next Gen NCLEX® unfolding case studies and stand-alone NextGen items (20% of each question bank).
CJE in actionSince implementing ExamSoft and CJE, The University of Toledo – College of Nursing has been able to enhance their approach to NCLEX® readiness and gain key performance insights to help prepare students for exam day. “We’re ahead of the game on the NCLEX® Next Gen because we have ExamSoft,” says Dr. Holly Myers, Instructor in the GEM program at The University of Toledo College of Nursing.
CJE Build-Your-Own Question Bank for new nurse educatorsNurses who have recently transitioned from the clinical setting to the academic setting may find their new role difficult at first. After all, nursing school and practice did not teach them pedagogy, and there is a lot to learn. Writing valid and reliable exam items, for instance, can be difficult for even the most experienced nurse educators.
New nurse educators may use older exam items as a start. But these items may not cover clinical judgment and most likely won’t be aligned with the Next Generation NCLEX®. These questions may also be available to students online or elsewhere, which can make it difficult to maintain academic integrity. CJE removes both of these concerns.
Written by nurse educators and clinicians, and continually analyzed by nurses in the field, the questions included with the CJE Build-Your-Own Question Bank are focused on clinical judgment and developed in alignment with the Next Generation NCLEX®.
CJE Build-Your-Own Question Bank from NurseThink® and ExamSoftThe CJE Build-Your-Own Question Bank covers up to 15 focus areas, including a Next Generation NCLEX® Readiness exam. Nurse educators can use these to supplement their own exam items or arrange them to fit their needs. CJE questions focus on clinical judgment and aid both experienced nurse educators as well as those new to the classroom.
Because CJE is only available through ExamSoft’s secure, digital platform, test items are safe from integrity breaches, maintaining exam validity. Activating complete device control prevents access to external programs, screensavers, and web browsers — everything but the test itself — while an exam is in session.
CJE questions are categorized in accordance with the NCLEX Client Needs, QSEN, and Clinical Judgment Measurement Model (CJMM). Strengths & Opportunities Reports from ExamSoft break down student performance by each of these categories, giving educators actionable insights to provide targeted remediation, adjust teaching methods, and fill gaps in curriculum — all with the focus of improving Next Generation NCLEX® pass rates and, ultimately, patient care.