NUR 640 Module 2 Item Writing Paper Example

Writing Clinical Judgment Items: A Six-Item Unfolding Sepsis Case Mapped to the NCSBN Model's Cognitive Functions

[Student Name]

Southern New Hampshire University

NUR 640: Assessment and Evaluation in Nursing Education

Module Two Item Writing Paper

[Instructor Name]

[Date]

Writing Clinical Judgment Items: A Six-Item Unfolding Sepsis Case Mapped to the NCSBN Model's Cognitive Functions

A student who can define sepsis may still miss it at the bedside. Traditional multiple-choice items often test whether students remember facts, while the decision a new nurse faces is whether a set of changes in one patient adds up to an emergency and what to do first. Since April 2023, the Next Generation NCLEX has measured clinical judgment directly through unfolding case studies and new item types. At Lakemont College of Nursing, a composite program, faculty found that most unit exam items tested recall, and first-time pass rates had dropped. This paper builds a six-item case on early sepsis for second-year students. It argues that mapping each item to one cognitive function, writing to established item rules and anchoring answers in current guidelines produces items that measure judgment rather than memory.

The Framework Behind the Items

The NCSBN Clinical Judgment Measurement Model describes clinical judgment as six cognitive functions that show up in a test taker's responses: (1) recognizing cues, (2) analyzing cues, (3) prioritizing hypotheses, (4) generating solutions, (5) taking action and (6) evaluating outcomes. Dickison et al. (2019) show how these functions align with frameworks nursing faculty already use, including the nursing process and Tanner's clinical judgment model, so that faculty can teach and test the same thinking. For item writing, the model's value is precision. Instead of writing a question about sepsis, the educator writes an item that asks students to do one specific thing with the case data, which makes it easier to see which step of reasoning a student has not yet mastered.

The Case

The case is an 81-year-old woman admitted from home with community-acquired pneumonia. The first screen shows admission data: temperature 38.4 degrees Celsius, pulse 104, blood pressure 118/70, 24 breaths a minute, oxygen saturation 92% on 2 liters, new confusion reported by her daughter and a white cell count of 15,800. Four hours later the case unfolds: blood pressure 86/50, heart rate 118, urine output 15 mL per hour for two hours, mottling over both knees, which feel cool, and lactate at 4.1 mmol/L. The final screen follows the first hour of treatment. Details are chosen so that some data matter and some do not, because distinguishing relevant cues is part of the construct.

Item Blueprint

The blueprint in Table 1 assigns one cognitive function and one format to each item. Formats are chosen for fit, not variety: highlighting suits cue recognition because the student must find the data in a realistic note, while a bow-tie suits taking action because it asks the student to connect a condition, actions and monitoring in one response.

Table 1. Item Blueprint for the Unfolding Sepsis Case

Note. One item per cognitive function lets faculty see which step of reasoning each student has not yet mastered.

Anchoring the Keyed Answers

Every keyed answer must be defensible from current evidence rather than a textbook edition. For Item 4, the keyed orders follow the 2021 Surviving Sepsis Campaign guidelines: obtain blood cultures before antibiotics without delaying them, give antimicrobials immediately and ideally within one hour when septic shock is possible, measure lactate, give 30 mL/kg of intravenous crystalloid within three hours when sepsis has caused hypoperfusion and target a mean arterial pressure of 65 mmHg (Evans et al., 2021). Distractors are plausible but incorrect for this patient, such as a diuretic for the low urine output or waiting for culture results before antibiotics. For Item 1, qSOFA is not the keyed screening concept, because the same guidelines advise against using it as a single screening tool compared with broader tools such as SIRS or early warning scores. Each key is recorded with its source so that reviewers can check it and future faculty can update it when guidelines change.

Applying Item-Writing Rules

Haladyna et al. (2002) reviewed textbooks and research on multiple-choice item writing and consolidated 31 guidelines. Several shaped this set. Each stem states a clear task, so a student could answer from the case without seeing the options. Negatively worded stems, such as "which action is not appropriate," are avoided because they test reading more than knowledge. Options are homogeneous in content and similar in length, so the longest option is not a clue. "All of the above" is never used. Distractors come from real student errors gathered from the formative cards in the previous module, such as confusing low urine output from dehydration with hypoperfusion, which makes them plausible to students who have not reasoned through the case.

Because the Next Generation NCLEX uses partial-credit scoring, the items are scored the same way. Items 4 and 5 use plus-minus scoring, in which each correct selection earns a point and each incorrect one loses a point, with a floor of zero, so that selecting every option cannot earn full credit. Faculty will discuss this with students before the exam so the scoring does not come as a surprise.

Review Before Use

Before the case is used for a grade, two faculty members who did not write it will answer it independently and check each key against the cited guideline. A small group of fourth-semester students will think aloud while completing it, which reveals ambiguous wording that faculty miss. After the first use, item difficulty and discrimination will be calculated, and items that strong students miss more often than weak students will be revised. The case will be tagged with its guideline date so that it is reviewed when the Surviving Sepsis Campaign next updates its recommendations.

Fairness is checked as part of the same review. Reviewers will look for wording that depends on cultural knowledge unrelated to nursing, idioms that multilingual students may misread and names or details that could cue a stereotype. The case uses plain clinical language, and the daughter's report of confusion is phrased as a direct quotation so that students do not need to infer it from an idiom.

Conclusion

Clinical judgment items take more time to write than recall questions, but they measure what the licensure examination and the bedside demand. A case built around the six cognitive functions, formats chosen for fit, keys anchored in the 2021 sepsis guidelines and distractors drawn from real errors, followed by structured review, gives Lakemont faculty evidence of how their students think, not only what they remember.

References

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337

Haladyna, T. M., Downing, S. M., & Rodriguez, M. C. (2002). A review of multiple-choice item-writing guidelines for classroom assessment. Applied Measurement in Education, 15(3), 309-333. https://doi.org/10.1207/S15324818AME1503_5