1. Gebhardt, Mary C. PhD, RN, CRRN
  2. Clifford, Barbara A. MNEd, RN, C
  3. Bates, Teresa A. MSN, RN

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Imagine this: you're an instructor of nursing. To remain curent, you don't rely on textbooks; rather, you use journal articles to show your students that evidence-based practices are replacing many time-honored traditions. But one day several students come to you, angry after receiving the results of their National Council Licensure Examination (NCLEX). It seems that the newest evidence-based practices you'd presented them in class weren't even given as choices on the examination.

Figure. Gebhardt... - Click to enlarge in new windowFigure. Gebhardt
Figure. Clifford... - Click to enlarge in new windowFigure. Clifford
Figure. Bates... - Click to enlarge in new windowFigure. Bates

One area in which your students might have been penalized is the assessment of returning gastric motility in postoperative abdominal surgery patients. In the December 2005 issue of AJN, Madsen and colleagues suggested that auscultation-listening for the presence of bowel sounds in all four quadrants for a full five minutes each-isn't the best way to assess these patients. They presented evidence showing that passing flatus or stool are good indicators of the return of gastric motility after abdominal surgery. Such an assessment was found to be not only quicker to perform but more effective (bowel sounds alone may not actually indicate a return of gastric motility).


We recently reviewed textbooks used in nursing programs and found that not all recommend the new technique. Nor is it reflected in the NCLEX review material. The Course Book: Preparation for the NCLEX-RN Exam, 7th edition, recommends auscultation for bowel sounds; other review material, such as Lippincott's Review for NCLEX-RN, 8th edition, recommends assessing for the passage of the first stool postoperatively. How is even the best-prepared student to answer a test question on this subject?


At a recent National Student Nurses Association conference presentation on evidence-based practice, some nursing school faculty members mentioned that they were aware of this specific change in practice, and some said that they present the material from the textbook, followed by a disclaimer: "Since we have conflicting information in different textbooks, for the NCLEX, you should know both recommendations." Other faculty members said that in the current academic setting, they don't have time to present both assessment methods, and they often teach only what's required to pass the test. This undermines what we know to be the best practice.


It takes three to five years to write, publish, and market textbooks, and two years to develop new NCLEX questions based on them. It isn't surprising that books and test questions are outdated. This interval should be shortened, and new test questions should focus not on specific clinical techniques but on the reasons for their use. For example, a question like "After abdominal surgery and before feeding the patient, the nurse should assess for return of gastric motility using which of the following assessment techniques?" could be revised: "After surgery and before feeding the patient, why should the nurse assess for gastric motility?" Changing the focus in this way would promote critical thinking and its application to clinical practice. That's what educators strive for and what serves patients well.


Such a change might necessitate, for example, more experienced nurses acting as mentors to new hires, to help them bridge the gulf between textbook and clinical work. Passing the test is important. But it's more important for new nurses to be encouraged to apply what they've learned.