Assessing Clinical Judgment: The Influence on Nursing Retention : Nursing Education Perspectives

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Assessing Clinical Judgment: The Influence on Nursing Retention

Serafini, Dodie

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Nursing Education Perspectives 44(2):p 135, 3/4 2023. | DOI: 10.1097/01.NEP.0000000000001100
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The ongoing nursing shortage has driven nursing education programs to seek solutions to maximize the numbers of qualified applicants accepted into programs. Feeding the profession with newly licensed nurses is necessary to offset the anticipated retirement of large numbers of professional nurses and anticipated health care demands. However, the influx of greater numbers of new graduate nurses has challenged employers to create pathways and practices that support their transition to practice and their retention. The additional resources allocated to new graduates are limited and costly. Employers report that new graduates require additional clinical education and mentoring practice of six to nine months on average. As a result, many employers limit the numbers of new graduates hired each year. A study completed by NSI Nursing Solutions (2022) reported that nurses employed less than one year have a turnover rate of 31 percent.

Newly prepared nurses report dissatisfaction with workload, challenges adapting to nursing, lack of confidence, and lack of knowledge and skills to deliver safe patient care (Ulipinar & Aydogan, 2021). Their retention must be considered with equity to the numbers of new nurses graduating and entering practice. Increasing the ability of newly prepared nurses to practice using clinical rationales will build confidence, enhance their knowledge and skills, and improve the management of assigned patient loads (Conner et al., 2022). Developing clinical judgment is critical to making accurate nursing diagnoses and clinical decisions (Standing, 2020). Improved patient outcomes and safe clinical practice are dependent on nurses who can make accurate and timely clinical decisions (National Council of State Boards of Nursing).

One quality measure of prelicensure nursing education programs is their national licensure exam pass rates. On April 1, 2023, the National Council of State Boards of Nursing (NCSBN) will begin using a revised licensure testing format intended to measure clinical judgment. NCSBN (n.d.) has defined the steps of the clinical judgment model and has added question types to assess the testers’ ability to filter, prioritize, and apply patient information. These steps are as follows: recognize cues, analyze cues, hypothesize, generate solutions, take action, and evaluate outcomes.

The new NCLEX will include a minimum of three case studies presented along with a portion of a patient’s record. There will be six questions presented per case study, one for each of the steps of the clinical judgment model. Unlike traditional item writing, intentional extraneous information will be included and available to the tester. To respond to questions accurately, the tester must decide what information is important to the patient’s clinical situation.

The clinical judgment model requires testers to seek out cues and process their meaning to determine the need for interventions and prioritization of care. NCSBN has many resources available for testers and nursing education programs. As licensure pass rates are high stakes for nursing education programs, programs must implement formative clinical judgment assessments throughout the curriculum to expose students to the various new question types. The outcomes of these assessments can be used for remediation or to identify changes needed within the curriculum to better encourage the development of clinical judgment.

Nursing education programs made tremendous adjustments to support the progression of students during the pandemic, reducing the time available for faculty to revise the curriculum and assessments to develop clinical judgment. As nursing programs begin to normalize, there must be a greater emphasis on preparing students for success with the next generation of NCLEX. Developing clinical judgment will increase the confidence of new graduates, support improved patient outcomes, reduce errors, and increase retention (Sherrill, 2020).

The Assessment Services Division of the National League for Nursing utilizes the services of nurse educator volunteer committee members who are trained to write next-generation formatted items to revise many of our assessments and NCLEX reviews. Developing item-writing skill requires time and intention. Committee members leverage the knowledge of those more proficient with item writing to help them advance. Each item is reviewed by several committees and beta tested prior to being placed on a secured assessment. The Assessment Services Division has assessments for program entry, advanced placement for practical or vocational nurses into registered nursing programs, content-specific and NCLEX readiness assessments, and NCLEX reviews. An end-of-program clinical judgment assessment is coming soon. Detailed information is available at


Conner J., Flenady T., Massey D., Dwyer T. (2022). Clinical judgement in nursing: An evolutionary concept analysis. Journal of Clinical Nursing. Advance online publication. 10.1111/jocn.16469
National Council of State Boards of Nursing. (n.d.). 2023 NCLEX-RN test plan.
NSI Nursing Solutions, Inc. (2022). 2022 NSI national health care retention & RN staffing report.
Sherrill K. J. (2020). Clinical judgement and next generation NCLEX®: A positive direction for nursing education! Teaching and Learning in Nursing, 15(1), 82–85.
Standing M. (2020). Clinical judgement and decision making in nursing (4th ed). Learning Matters.
Ulipinar S., Aydogan Y. (2021). New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study. Journal of Nursing Management, 29(6), 1830–1840. 10.1111/jonm.13296
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