Editorial: High Stakes Evaluation in Nursing Education-Moving Beyond the Multiple-Choice Question

Editorial

The Think Tank on Simulation for High Stakes Evaluation in Nursing Education was a 3-year project that was undertaken by the National League of Nursing (NLN). It was sponsored by Laerdal Medical with a purpose of studying the use of simulation for high-stakes evaluation in nursing education. Previous research conducted and sponsored by the aforementioned organization had documented the value of simulation as a teaching method and provided guidelines how to effectively design and implement simulation scenarios. Nevertheless, they found little evidence that supported the use of simulation in the evaluation of nursing students’ clinical competency in nursing schools. The project was designed to identify end- of-program outcomes that were amenable to evaluation via simulation. Another goal would be to develop a series of simulation scenarios that could be utilized for summative end-of-program evaluation within pre- licensure RN programs. Such pre-licensure programs would include associate degree, diploma, and baccalaureate nursing education institutions [1]. The reasons the NLN and Laerdal Medical pursued such research is due to the context of nursing education today. Many contextual factors of nursing education support the goals of the think tank, whereas others act as barriers. Traditional methods of evaluation such as multiple choice questions are pervasive throughout the United States. Nevertheless, this is not the case in other parts of the world. The think tank calls into question why this method continues to be the predominant way educators measure competence. The use of multiple choice questions as an evaluation tool focuses on assessment on low-level skills rather than on higher-order professional skills such as integrating evidence, thinking, and synthesis into one’s practice [1]. Many faculty despite having a desire to change the ways students are evaluated, do not know which of the newly forming assessment methods are effective. Other faculty are “risk averse” and are “afraid to let go”. A barrier to this project is that skepticism exists regarding whether simulation truly “works”. Other faculty are resistant to calls for changes in program philosophy, course delivery, and objective assessment methods. This is due to anticipation of how doing so will add to their already-heavy workloads [1]. Despite such barriers to the goals of the project, there are many trends in nursing education that support the think tank’s mission. The shift of behavioral objectives to competency outcomes supports such a summative form of evaluation. Many have begun to question whether the capstone experiences used in schools of nursing truly promote the achievement of stated outcomes. Employers wish to hire nursing graduates who possess a wide variety of skills such as critical thinking, priority setting abilities, clinical judgment, and direct care nursing skills. There currently is a widening gap between what nursing graduates are able to do and what employers want of them [1]. As a nurse educator, I have seen how many students struggle with test taking strategies whereas others have a great advantage because of their skills in this area (taking Nursing & Healthcare International Journal

tests and answering multiple choice questions). I remember being in nursing school with students who did phenomenally well in clinical simulation or the clinical setting but who were unable to pass tests. It was not that they did not possess knowledge necessarily. This was made evidenced by how they excelled in the clinical area. Nevertheless, because they did not pass a multiple-choice test, the clinical performance did not count. Likewise, there were students who did well on tests, but who did not excel in the clinical setting. I question today whether multiple choice tests are a true measure of nursing competence. This puts into perspective how this topic impacts the Institute of Medicine’s (2001) [2] recommendation that health care be “safe, effective, efficient, timely, personalized, & equitable”. How can nursing education professionals be accountable to the public in such a way when they have no concrete evidence that supports that higher order professional skills of students have been assessed? Without evidence of evaluation techniques that prove students can provide safe and effective care beyond a piece of paper and pencil or computer screen, the public is put at risk. I would make a recommendation on the state and national levels to reconsider the use of mostly multiple choice questions in the evaluation of nursing graduates via the National Council Licensure Examination. It cannot be verified that all nursing graduates who pass the NCLEX have all of the skills necessary to satisfy the needs of the public. Dyess & Sherman (2009) [3] explain that there is an apparent disconnection between nursing education and practice. As a result, this threatens the transition of new graduate nurses to professional practice. One student described how it felt to be a new nurse as if one is acting like a nurse, but they feel as if they are not truly a nurse yet. Another novice nurse described the experience as a mix of fear and emotion stating: “And I find it’s a fusion, a mix of fear for being the responsible one, and a challenge; to put all my knowledge properly together in every situation” (p. 406). Summative testing should test the many skills of nursing students by adding a simulation component.