Nursing Exams and Health Checkups: Achieving and Maintaining Optimal Performance

Tony Juve, PhD

Psychometrician

Nursing exam maintenance can be compared to maintaining physical health. Scheduled checkups and occasional lifestyle changes are needed to maintain optimal performance. The same holds true for nursing exams which also require regular checkups to identify the existing level of health and needed changes for optimal exam performance. A review of literature reveals nurse educators do not consistently evaluate the performance of their items or the overall performance of exams. Eight percent of nurse educators are not using any type of item analysis on their exams, and 29% only use one type of item analysis (Moran et al, 2022).

Exam analysis is a critical component in nursing education. Following a structured process and making needed revisions promotes optimal assessment of required student knowledge. The exam development and analysis process is rigorous and should include following the Standards for Educational and Psychological Testing, the gold standard of testing, paralleled with professional accreditation standards, and evidence based practice. When developing a newly written exam, consider a small team approach and include a subject matter expert, psychometrician, and copy editor to review grammar, punctuation, and spelling. An exam item template can promote efficiency during the writing and editing process. For existing exams, consider the following questions.

How often are nursing exams being assessed?

A periodic review of exams should be done to determine if revisions are needed. Revisions are often required when new research data impacts an existing standard of practice, or new test use conditions or interpretations suggest the test is no longer fully appropriate for its intended use. When determining if a nursing exam needs to be revised, consider the following questions:

• Has the exam become notably more difficult or easy?

• Has the reliability of the exam significantly decreased? For example, reliability changes from good (α=.85) to questionable (α=.65).

• Has the allotted testing time been markedly reduced? For example, testing time was reduced from 2 hours to 1 hour.

If a response of “yes” is given to any of the above questions, consider a major exam revision to increase validity of the exam. If a response of “no” is given to all of the questions for overall health of your exam, move forward to the next question.

How often are exam items being assessed?

When determining if items need to be revised, consider the following questions:

• Is the item content outdated?

• Is the item too easy (i.e., ≥ 90%) or too difficult (i.e., ≤ 29%)?

• Does the correct answer (i.e., key) negatively discriminate? For example, low performing students select the key more frequently than high performing students.

• Does a wrong answer (i.e., a distractor) positively discriminate? For example, high performing students select the distractor more frequently than low performing students.

• Is a wrong answer not plausible to the students? For example, none of the students selected the wrong answer.

If you responded “yes” to any of the above questions, consider revising items needing improvement. The above listed criteria is important to maintain the validity of nursing exams. Scheduling an overall assessment for exam health can be completed once the exam has been administered two or more times to gather data points and identify trends. Items can be assessed following the completion of each exam to maintain optimal performance. Scheduling and performing exam health checkups will promote validity of exams, and optimal exam performance allowing for an accurate assessment of student knowledge!

Thank you for ALL you do!

For additional information, visit:

American Educational Research Association, American Psychological Association, & National Council on Measurement in Education (Eds.). (2014). Standards for educational and psychological testing. American Educational Research Association. https://www.aera.net/Publications/Books/Standards-for-Educational-Psychological-Testing-2014-Edition

Moran, V., Wade, H., Moore, L., Israel, H., & Bultas, M. (2022). Preparedness to write items for nursing education examinations: A national survey of nurse educators. Nurse Educator, 47(2), 63–68. https://doi.org/10.1097/NNE.0000000000001102

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April 30, 2025