The format of the National Council Licensure Examination (NCLEX) will undergo major changes that will be implemented in 2023. The goal of this change is to accurately measure nursing clinical judgment, a construct that is difficult to assess using the current NCLEX test items. The purpose of this article is to analyze Cloze items, which will be featured in the NextGen NCLEX.
Psychometric Properties
At a basic level, Cloze items are fill-in-the-blank questions with a drop-down menu of possible responses. The goal of the test item is to assess the student's ability to choose the word that best fits into the sentence based on the scenario. To assess nursing knowledge rather than reading ability, the item must be written at an appropriate readability level. The National Council of State Boards of Nursing uses both the Fry method and the Lexile scale, which are tools to measure the reading level of the NCLEX. The current standard is the NCLEX reading level should not exceed 10th grade reading level.1 Cloze items used in the health professions demonstrate good reliability and validity.2Table 1 illustrates 3 Cloze items used in a medical surgical nursing examination.
The difficulty level of items 1 to 3 (Table 1) ranged from 0.68 to 0.41, suggesting that these were difficult items in which only 41% to 68% of the students selected the correct response. Discrimination index is a measure of how well the item discriminates between the high-performing and low-performing students. A discrimination index greater than 0.40 is considered excellent.2 In this group of Cloze items, high-performing students scored well, and lower-performing students did not score well. The point biserial measures the correlation of performance on test items with the total test score. A large point biserial indicates that an item is measuring the same construct as the overall test measures. A high point biserial also indicates that examination takers who performed well on the examination also selected the correct response, thus further discriminating between high- and low-scoring students. The point biserial for a very good item should be greater than 0.30, which suggest that the items in Table 1 provided good discrimination between high- and low-performing test takers.2
The last column shows the Kuder-Richardson (KR20) for each examination. The KR20 is a measure of reliability of the entire examination rather than a reflection of the item itself. An acceptable KR20 is higher than 0.60 for examinations with smaller samples and higher than 0.70 for larger sample sizes.3 An examination that was solely dedicated to cardiac nursing should have a higher KR20 because most of the content is from a similar domain. The KR20s of these examinations demonstrated a high level of reliability of each examination.
Scoring
Traditionally, nursing test items are scored with an all or nothing approach. This classic approach allots a set number of points for each test item. If an incorrect option is selected, no point would be earned for that item. Because of the complexity and length of Next-Generation NCLEX test items, an all-or-nothing approach would not accurately measure nursing clinical judgment. The test items have multiple layers and several opportunities to demonstrate competence within 1 item. Strategies to award partial credit should be explored when scoring NextGen items.
One option to consider is the "+/- scoring rule." This method of scoring is derived from the Signal Detection Theory.4 Signal Detection Theory can be used when 2 possible stimulus types must be discriminated. The basic premise of this scoring method is the student will earn points for selecting the correct answers and lose points for selecting an incorrect answer. This method would work well in the Cloze item in Table 2. In this item, there are 4 drop-down choices within the scenario. When using the +/- scoring rule, the item can be assessed using the strategy shown in Table 2.
Example of Cloze Items in a Case Study
Cloze items are versatile and can be easily integrated into classroom activities, quizzes, and examinations. One way to incorporate this item type in both examinations and in-class activities is to construct an evolving case study. The Supplemental Digital Content, http://links.lww.com/NE/A972, provides an example of a complex case study with multiple Cloze items and scoring using the +/- scoring rule.
Integration into classroom activities is relatively simple. One example is to create groups of 3 to 4 students each to work on different case studies. Each case study can include a paragraph with at least 10 fill-in-the-blanks. Give the students numerous options for each case study. Each group can present its results to the class for feedback and discussion.
NextGen NCLEX will be implemented very soon! Schools of nursing should promptly start incorporating active learning strategies into the classroom to prepare for this change.
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