Psychiatric nursing at risk: the new NCLEX-RN Test Plan.

Abstract

A new NCLEX-RN Test Plan (National Council of State Boards of Nursing [NCSBN], 2003) that became effective in April has decreased the number of questions from 12%-22% to only 6%-12% of the total content. Several steps were used in the development of the new test plan. In 2002, a survey sent to more than 4,000 newly licensed nurses asked about their current practice as entry-level nurses, specifically about the frequency and priority of more than 130 nursing care activities (Smith & Crawford, 2003). The examination committee of the National Council of State Boards of Nursing (NCSBN), consisting of 10 nurses, reviewed the survey results and made recommendations to the Delegate Assembly, the policy-making body of NCSBN. The assembly approved the new test plan as a blueprint for test-question development that will guide the selection of content and behaviors to be tested on future licensure exams. A revision of the passing standard was needed, according to the NCSBN, because patient acuity has increased in the U.S. healthcare delivery system. Safe and effective entry-level RN practice requires a greater level of knowledge, skills, and abilities than was required when the last revisions were made in 1998 (NCSBN, 2004). Unfortunately, the assessment was made that greater knowledge did not include greater understanding and application of psychiatric and nursing content. How did this happen? Apparently, the 4,000 nurses surveyed did not identify as a priority many nursing activities that qualify for the category of psychosocial and the NCSBN concluded this was not a priority area to be tested. How can anyone, new graduate nurses or NCSBN, say that the emotional and mental well-being of patients is less important than the physical care? One in five Americans is living with a mental illness, and if treatment is obtained, it is usually dependent on the skills of generalist nurses and other healthcare providers. It is estimated that one-half of all visits to primary care physicians are related to conditions that are caused or exacerbated by mental or emotional problems (U.S. Department of Health and Human Services [USDHHS], 1999). Is it possible that interventions are not frequently implemented along with physical care because nurses need more education in this area? It is a major concern that the percentage of questions devoted to the psychosocial integrity category is being significantly reduced. We have no way of knowing if the questions will be focused on evidence-based healthcare assessment of psychiatric patients or nursing care interventions to meet these needs. The 6%-12% of questions could be on anxiety in the surgical patient, grieving parents who lost a child, or the adjustment of a patient to the loss of his leg--without as much as one question on psychiatric disorders and the appropriate assessments and interventions. The de-emphasis of integrity, and specifically psychiatric mental health nursing and clients with mental illness diagnoses, comes at a time when we know that one-fourth of all health disabilities are related to psychiatric/mental health and substance-abuse disorders. Mental illness-related problems are a major source of disability and morbidity for children, adults, and the elderly. The Surgeon General's report (USDHHS, 1999) alerted the nation to the fact that more than 54 million Americans have a mental illness in any given year, although fewer than 8 million seek treatment. Mental illnesses such as major depression, manic-depressive illness, schizophrenia, and obsessive compulsive disorder are leading causes of disability. Mental illness also is a contributor to mortality, with suicide being one of the leading preventable causes of death in the United States. Evidence-based data support the need for this country's more than 2.7 million nurses and its new graduates to be able to identify emotional disorders and behaviors indicative of mental illness and provide care and/or resources for care. …