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Debriefing Beyond Simulation: Using Plus-Delta-Plus to Debrief Real Patient Events

Christopher Roussin
Posted on March 16, 2017
"Simulation educators, especially novices, can be overwhelmed by the
complexity of facilitating debriefings, and practical guidance is needed."
-Adam Cheng and Walter Eppich
Your colleagues are gathered in a circle after experiencing a difficult clinical care event. You try to read their faces. Some show confusion, others frustration or concern and others hope and enthusiasm. You feel your face flush as you shuffle your papers and take a deep breath...

The value of facilitated debriefing, after both simulations and real patient events, is now clearly established in the academic literature. Most clinicians have had one or several positive debriefing experiences. Still, leading a debriefing session can be intimidating, even for those with advanced "people skills," and skilled facilitators can seem almost magical in their ability to lead complex conversations. Many would-be facilitators worry about appearing to "judge" valued colleagues or causing more damage than benefit.

How can debriefing be made easier, so that more facilitators feel confident enough to lead positive, developmental conversations? One answer is to use a simpler debriefing approach so that facilitation is easier to learn and practice. Another answer is to rethink feelings of "judgment;" to take the focus off worrying about offending colleagues and instead embracing the role of positive, developmental guide. But these approaches put the onus on the sole facilitator. There is still a need for an easily executed, replicable, flexible, trainable method of debriefing.

Enter Plus-Delta-Plus, a refinement and repackaging of existing debriefing methods that makes debriefing easier and less worrisome for both novice and experienced facilitators. Using a series of structured steps, Plus-Delta-Plus clearly shifts responsibility for identifying performance gaps (and achievements) from the facilitator to the team of debriefing participants.

After welcoming the team and introducing the debriefing process, the facilitator invites the team to produce a "Plus/Delta" chart describing "what went well" (Plus) and "what could be improved" (Delta). Next, the facilitator guides the team through a review of the chart, followed by a deeper exploration of two to three salient items. This deeper dive includes development of solution-based "next steps" to encourage positive behaviors and develop new ones.

Plus-Delta-Plus is currently being used by multi-disciplinary teams in Boston Children's NICU after both simulations and real patient events. It has already strengthened the culture of safety and collaboration in the NICU.

"This simple, efficient framework helps teams focus on crisis event review in an effective way," reports Dr. Kristen Leeman, the NICU's associate medical director. "Systems changes, individual personal development and improved team dynamics have all resulted from our Plus-Delta-Plus debriefing sessions."

BY THE NUMBERS:

In FY16, the Simulator Program ran 603 course meetings. The majority were in the Boston Children's Residency Program, Department of Medicine, Emergency Medicine, Anesthesia, Cardiology, Nursing and Surgery. There there were 37 courses at network hospitals. Another 14 programs are being developed for FY17.

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Christopher Roussin Posted on March 16, 2017 "Simulation educators, especially novices, can be overwhelmed by the complexity of facilitating debriefings, and practical guidance is needed." -Adam Cheng and Walter Eppich Your colleagues are gathered in a circle after experiencing a difficult clinical care event. You try to read their faces.

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Debriefing for Clinical Learning | AHRQ Patient Safety Network

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Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.

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Please see below for key information about our services during the current national lockdown. Updated 12 January 2021.

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Please see below for key information about our services during the current national lockdown. Updated 12 January 2021. Both our Libraries remain open Monday - Friday 09:00 - 21:00 and Saturday - Sunday 11:00 - 17:00. However, please only come to the Library if it is essential.

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Infographics - Infographic Design by Column Five

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Measuring Return on Investment in Nursing Professional Development

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tools and information about evaluation of education

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Ever heard of Teach Back? Join some of the least-known voice talent in the business once again as we describe this simple yet powerful practice that can really make a difference in interactions with your patients.

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The Clinical Nurse Educator as Leader

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10 Teaching Strategies

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Mentimeter: Interactive quizzes, surveys, multiple choice tests and more

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August 2010 Vol. 5 No. 8

Author(s):

Let's assume for a moment that you just graduated from nursing school. You have a brand new degree, a little clinical hospital training, lots of new information, and a brief job as a nursing assistant in a community living center for geriatric residents. The hospital of your dreams just hired you as a registered nurse. Now you begin the hospital's new employee orientation. After filling out far too many forms of various sizes, colors, and readability, you are introduced to the other new employees. Next comes your clinical orientation.

Or perhaps you are an experienced nurse but a new hire to the hospital. Once the general hospital orientation is done-the same one new nurses and every other new employee usually goes through-you meet the Nursing Professional Development Specialist (NPDS; also known as nurse educator). This is the person who will guide you into all things clinical, with knowledge, skill, and encouragement.

The NPDS then introduces you to your preceptor. You, your preceptor, and the NPDS meet regularly to assess your progress and comfort in your new position, evaluate your competencies, and determine what training, support, and resources you will need to be successful. The NPDS will also be an ongoing member of your career development team.

What is an NPDS?

Nursing Professional Development Specialists have knowledge and skills in adult learning principles, nursing career development, program development and management, continuing education, and leadership. The American Nurses Association identifies this practice specialty, which is based on the sciences of nursing, technology, research and evidence-based practice, change, communication, leadership, and education as Nursing Professional Development.

These experienced educators help nurses engaged in lifelong learning to develop and maintain their competencies, advance their professional nursing practice, and facilitate their achievement of academic and practice career goals. They work in a variety of practice settings and environments of care. Some are in schools of nursing and facilitate the learning experiences of students seeking to become nurses. Others work in clinical settings to orient, precept, and manage competencies of staff nurses, new graduates, and student nurses working at the point of care. Clinical NPDSs (sometimes called clinical nurse educators) support nursing research, evidence-based practice, and quality improvement through professional nurse development.

Multiple hats
Throughout your orientation and clinical advancements, you discover that NPDSs wear many hats. They are educators, servant leaders, facilitators, consultants, change agents, coaches, and researchers. They orient, precept, mentor, encourage, and guide your transition into your new role, position, and future. They show you how to manage and validate your competencies and build your confidence through engagement and feedback. They review your portfolio of training, experiences, accomplishments, inservices, and continuing education to help you identify strategies for developing your proficiencies related to competency, practice, and quality at the point of care.

Some of the many ways NPDS contribute to your lifelong learning and ethical practice development are woven into their roles:

Educator. Nursing Professional Development Specialists assess your learning needs, competencies, strengths, and opportunities to improve your critical thinking, interpersonal, and technical skills. They provide frequent feedback and evaluate outcomes. As you learn, they help you continue to build your knowledge and levels of competency in clinical practice in your work area or in specialty areas that interest you, such as gerontology or pediatrics. They collaborate with you to determine your needs if you choose to advance your practice towards certification and/or another academic degree. Sometimes they serve as faculty in colleges and universities, which allows them to better mentor you in deciding a best fit for your continued professional development.

Change agent. Nursing Professional Development Specialists engage intra- and interprofessional groups in problem-solving, team building, and incorporating changes in individual and organizational needs. They identify healthcare issues and help you stay current in the latest evidence for new practices and quality indicators through learning activities, inservices, and information-sharing. They might help you assess and address behaviors that interfere with your ability to get your work done effectively, such as showing you how to reorganize your time, prioritize your activities, and delegate appropriate tasks so that you are more confident and efficient in your work

Researcher. Nursing Professional Development Specialists facilitate evidence-based practice by bringing nursing research to the point of care. They advise, collaborate, translate, integrate, and evaluate research that is in the literature and/or in progress within the organization through practice, education, and reflective discussion with staff. If you have a practice question for which you cannot find an answer that satisfactorily explains the rationale given in the policy or by others orienting you, the NPDS becomes one of your most valuable resources. NPDSs guide you in the best ways to protect your patients from the potential for exploitation and harm when involved in clinical research. They directly engage you in research and evidence-based practice to help you improve your patient care outcomes and add to the body of nursing knowledge as you generate questions about better ways to care for your patients.

Servant leader. Nursing Professional Development Specialists provide encouragement, respect, support, boundaries, protection, and guidance that influence your transition into a professional, expert nurse. They integrate ethical principles, service, and leadership into all of their activities. In the process, they role model transformational leadership and professionalism, inviting you to do the same. They protect you from the wide chasms created by political and professional norms that can so easily be breached, especially when you are new and still finding your way. They show you how to engage your peers and other healthcare providers when you are asked to be the charge nurse or nurse leader for a team or unit so that you continue to work effectively in partnership with one another, with physicians, and with other services. This requires you to learn how to manage people ethically and responsibly so that you can influence them to focus their best expertise and experience in caring for their patients, even when you are relatively new to your position or workgroup.

Mentor. Nursing Professional Development Specialists guide you through the many pathways of your career, beginning with orientation to your first job. In fact, some began even sooner, when they met you in your college nursing courses and academic clinical experiences. They are the faculty members who assisted you with your professional development plan and showed you how to implement it. They advised you when you wrote your resume and later, your curriculum vitae. They listened as you struggled to decide which specialty to pursue and supported every false start until you found your way. They celebrated your graduation, your new job, and your first promotion with you. They pushed you to look beyond the 'now' to the future as you considered the many possibilities in advanced practice nursing, management, and a doctorate in nursing practice.

How would I become a Nursing Professional Development Specialist?
The answer to this question varies greatly from organization to organization, from state to state, and from job to job. There are some colleges that offer a master's degree in nursing education. However, most academic programs focus on preparing the student to teach in a college or university program rather than in a clinical setting with graduate or experienced nurses. Traditionally, hospitals have hired a clinical expert without specialized training in adult learning principles, continuing education, or staff development as their nurse educator or clinical nurse specialist in education, or a similar role. This is changing. Many hospitals now seek clinical experts who also have specialized training, certification, and experience in staff development. The best "first step" for anyone wanting to know more about this specialization is to become involved in the National Nursing Staff Development Organization ( https://www.nnsdo.org/) and network with the plethora of diverse nursing professional development specialists who practice in every conceivable type of healthcare organization.

Range of influence
Nursing Professional Development is like all specialties. It embodies the unique knowledge, skills, insights, and experiences of nurses who have advanced their practice into staff development, continuing education, and academia.

Nursing Professional Development Specialists work with a wide range of competencies, learning needs, and tiered academically prepared nurses across all practice settings and environments of care. They partner with healthcare providers and nurse leaders to ensure a safe, effective, and efficient environment of care. They are involved in project management, academic and clinical education, program and portfolio development, competencies management, continuing education and return on investment, leadership and relationship-building, research and evidence-based practice implementation, cybergogy (learning through technology), and nursing practice excellence. This is what NPDSs do. And they do this for you, the healthcare provider at the point of care.
Both authors work at the Bay Pines VA Healthcare System: Diana Swihart, PhD, DMin, MSN, CS, RN-BC, is the Magnet Program Director. She also serves as a Commissioner on Accreditation for the American Nurses Credentialing Center and is a member of the National Nursing Staff Development Organization. Diane Johnstone, MSN, RN, NEA-BC, is the Chief for Nursing Education at Bay Pines VA. Both are certified in their nursing specialties. Selected references
American Nurses Association. (2000). Scope and standards for nursing professional development. Silver Spring, MD: American Nurses Association (ANA) Nursebooks.

Avillion, A. E. (2008). A practical guide to staff development: Evidence-based tools and techniques for effective education (2nd ed.). Marblehead, MA: HCPro, Inc.

Bruce, S. L. (Ed.). (2009). Core curriculum for staff development (3rd ed.). Pensacola, FL: National Nursing Staff Development Organization.

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What does a Nursing Professional Development Specialist (Nurse Educator) do? - American Nurse Today

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Let's assume for a moment that you just graduated from nursing school. You have a brand new degree, a little clinical hospital training, lots of new information, and a brief job as a nursing assistant in a community living center for geriatric residents. The hospital of your dreams just hired you as a registered nurse.

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NLN Teaching Resources

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ACE.C (Advancing Care Excellence for Caregivers)

ACE.D (Advancing Care Excellence for Persons with Disabilities)

ACE.P (Advancing Care Excellence for Pediatrics)

ACE.S (Advancing Care Excellence for Seniors)

ACE.V (Advancing Care Excellence for Veterans)

ACE.Z (Advancing Care Excellence for Alzheimer's Patients and Caregivers)

Coaching for Excellence in Nursing

​ Fair Testing Guidelines (PDF)

Hallmarks of Excellence

Interprofessional Education (IPE)

NLN Reflections & Dialogue

NLN Vision Series (formerly Position Statements)

Practical Nursing Curriculum Resources

Simulation Innovation Resource Center (SIRC)

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ACE.C (Advancing Care Excellence for Caregivers) ACE.D (Advancing Care Excellence for Persons with Disabilities) ACE.P (Advancing Care Excellence for Pediatrics) ACE.S (Advancing Care Excellence for Seniors) ACE.V (Advancing Care Excellence for Veterans) ACE.Z (Advancing Care Excellence for Alzheimer's Patients and Caregivers) Coaching for Excellence in Nursing ​ Fair Testing Guidelines (PDF) Hallmarks of Excellence Interprofessional Education (IPE) NLN Reflections & Dialogue NLN Vision Series (formerly Position Statements) Practical Nursing Curriculum Resources Simulation Innovation Resource Center (SIRC)

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Journal for Nurses in Professional Development (JNPD)

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Journal for Nurses in Professional Development (JNPD)

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Journal for Nurses in Professional Development

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Article: Helping without harming: The instructor's feedback dilemma in debriefing

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Article: Helping without harming: The instructor's feedback dilemma in debriefing

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Feedback Dilemma for Sim Instructors with debriefing

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This tool kit was prepared by Hilda Haynes-Lewis, Jonas Veteran Healthcare Scholar (2014-2016) and Triniece Pearson, Jonas Nurse Leader Scholar (2014-2016) for the Graduate Nursing Student Academy (GNSA). AACN has not officially endorsed the materials contained therein.

Overview

The nursing shortage has fueled increased demand for nursing faculty. The average age of nursing faculty is increasing and many are expected to retire in the next decade. The demand to educate new nurses has led nursing schools to look for new solutions that solve the nursing faculty shortage. These solutions include developing new faculty roles that ease the transition from the bedside to academia. Since nursing faculty are on the forefront of creating the next generation of registered and advance practice nurses, increasing the number of nursing faculty, especially those of diverse ethnic backgrounds is also imperative to the advancement of the field.

Nurses are an integral part of the healthcare team. Changing from clinical to academic life and balancing both can cause role strain. Role strain stems from a conflict between the familiar expectations in your current role as a clinician and the new demands of an academic position. Taking time to thoroughly consider the transition to academia is the first step. This tool kit and webinar are here to inform and serve as a starting point when considering a faculty role. A guide to mapping out the transition and the responsibilities of desired faculty roles are discussed.

The purpose of this tool kit is to:

Explore the concept of role change and the impact of role change, from clinician to faculty, on the individual.

To provide a theoretical framework for transitioning into a faculty role as described in the literature.

To describe the faculty positions available for the clinician and provide a roadmap for attaining that position.

Note: The resources of this tool kit are not exhaustive. This document is a starting point of articles that inform the transition to nursing faculty.

The definition of role change or role transition has been described in the literature as any transition from one set of behaviors to another. According to Melesis (2010) role transition involves the need to attain new knowledge, changes in social status and interactions with others that may lead to feeling of instability and uncertainty since self-identity and role change can occurs simultaneously as you move from novice to master in the newly defined role.

Role theory posits that people learn to adapt to the roles given to them by society and the rules that are agreed upon by society for a given role. The roles that individuals have are learned behaviors (Goodling, 2003). Similarly Transition Theory states that people can learn and adapt to changes. Transitions theory notes that change happens over times therefore the experience of transition is fluid.
Suggested References
Anderson, J. K. (2009). The work-role transition of expert clinician to novice academic educator. The Journal of Nursing Education, 48(4), 203-208. doi:10.3928/01484834-20090401-02

Clark, N. J., Alcala-Van Houten, L., & Perea-Ryan, M. (2010). Transitioning From Clinical Practice to Academia. Nurse Educator, 35(3), 105-109. doi:10.1097/NNE.0b013e3181d95069

Goodling, S. M. (2003). Transition from academia to home health practice. Home Health Care Management & Practice, 16(1), 17-24. doi: 10.1177/1084822303260198

Meleis, A. I. (2010). Transitions theory: Middle-Range and situation-Specific theories in nursing research and practice. New York, EUA: Springer publishing company.

Ramsburg, L., & Childress, R. (2012). An initial investigation of the applicability of the
Dreyfus skill acquisition model to the professional development of nurse educators. Nursing education perspectives, 33(5), 312-316. doi.org/10.5480/1536-5026-33.5.312

Schoening, A. M. (2013). From bedside to classroom: The nurse educator transition model. Nursing education perspectives, 34(3), 167-172. doi.org/10.5480/1536-5026-34.3.167

The transition from the role of nurse clinician to that of faculty and a member of the academic society can result in internal conflict and cognitive dissonance since the expectations as a clinician and the multitude of demands of an academic position. Clarke et al (2010) states that this incongruence can result in role stress which has four causes; ambiguity, incongruity, conflict and overload, which are below.

Ambiguity

Ambiguity occurs when there is a deficiency of clarity surrounding the behaviors and responsibilities associated with the role are not well defined or understood by the parties involved; the clinician, the medical institution or the academic institution.

Ambiguity is a common occurrence because most clinicians have not been socialized into the culture of academe.

Incongruity

Incongruity is the incompatibility between the different aspects contained in the role. There can be conflict between the skills and abilities, values and expectations or role obligations.

Conflict

Role conflict arises when the expectations are perceived to be contradictory or incongruent and can result in irreconcilable demands on the part of the nurse or the institution.

Overload

Overload occurs when the demands of the roles or roles overwhelm the new faculty member resulting in difficulty in meeting the obligations of the role in the prescribed time.

Overload can lead to workplace tension, anxiety, and personal conflict that can result in the exhibition of negative behaviors.

Components of a Smooth Transition

Become immersed in academic culture by reading journals on nursing education in addition to clinical journals.

Suggested References

Anibas, M., Brenner, G. H., & Zorn, C. R. (2009). Experiences described by novice
teaching academic staff in baccalaureate nursing education: A focus on mentoring. Journal of Professional Nursing, 25(4), 211-217. doi.org/10.1016/j.profnurs.2009.01.008

Clark, C. L. (2013). A mixed-method study on the socialization process in clinical
nursing faculty. Nursing education perspectives, 34(2), 106-110. doi.org/10.5480/1536-5026-34.2.106

Clark, N. J., Alcala-Van Houten, L., & Perea-Ryan, M. (2010). Transitioning from
clinical practice to academia: University expectations on the tenure track. Nurse Educator, 35(3), 105-109.doi: 10.1097/NNE.0b013e3181d95069

Duffy, R. (2013). Nurse to educator? Academic roles and the formation of personal
academic identities. Nurse education today, 33(6), 620-624. doi.org/10.1016/j.nedt.2012.07.020

Gazza, E. A. (2009). The experience of being a full-time nursing faculty member in a
baccalaureate nursing education program. Journal of Professional Nursing, 25(4), 218-226. doi:10.1016/j.profnurs.2009.01.006

McDonald, P. J. (2010). Transitioning from clinical practice to nursing faculty: Lessons
learned. Journal of Nursing Education, 49(3), 126. doi:10.3928/01484834-20091022-02
Penn, B. K., Wilson, L. D., & Rosseter, R. (2008). Transitioning from nursing practice to
a teaching role. Online journal of Issues in Nursing, 13(3).
doi:10.3912/OJIN.Vol13No03Man03

Roberts, S. J., & Glod, C. (2013, April). Faculty roles: Dilemmas for the future of nursing
education. In Nursing forum (Vol. 48, No. 2, pp. 99-105).doi: 10.1111/nuf.12018

Schaar, G. L., Titzer, J. L., & Beckham, R. (2015). Onboarding New Adjunct Clinical
Nursing Faculty Using a Quality and Safety Education for Nurses-Based Orientation Model. Journal of Nursing Education, 54(2), 111-115. doi:10.3928/01484834-20150120-02

Weidman, N. A. (2013). The lived experience of the transition of the clinical nurse expert
to the novice nurse educator. Teaching and Learning in Nursing,8(3), 102-109. doi:10.1016/j.teln.2013.04.006

Ziehm, S., & Fontaine, D. K. (2009). Clinical faculty: tips for joining the ranks. AACN
advanced critical care, 20(1), 71-81. doi: 10.1097/NCI.0b013e31819453ab

Bednash, G., Breslin, E. T., Kirschling, J. M., & Rosseter, R. J. (2014). PhD or DNP: Planning for Doctoral Nursing Education. Nursing Science Quarterly, 27(4), 296-301. doi:10.1177/0894318414546415

Sonson, S. L. (2013). DNP-prepared APRNs: Leading the magnet?? charge. Nursing Management, 44(7), 49-52. doi:10.1097/01.NUMA.0000431425.39076.81

What Is Tenure?
A guaranteed job contract given to academic professionals that have shown skills over a period of time. It provides security from being laid off without sufficient justification. Primary responsibilities include: teaching and research, independent program of research, publications,teaching undergrad and/or graduate students, serving as an academic/research advisor of students involvement.

Tenured Positions

Tenured Professor
After all other promotions have been reached

Associate Professor
On-Track to be a Full Professor upon evaluation of requirements needed for promotion. These requirements may vary by University/department.

Assistant Professor
Entry level tenure-track position for PhD graduates. DNP graduates may also be eligible for entry-level tenure-track positions depending on the University. On-Track to be an Associate Professor upon evaluation of requirements needed for promotion. These requirements may vary by University/department.

Non-tenured Positions

Adjunct Faculty
Non-tenure/part-time/per course. Primary duty is teaching. This includes developing syllabi, coordinating curriculum, facilitating class instruction, evaluating student performance, holding office hours, maintaining course website (blackboard).

Bachelors Degree (Required)

Master's Degree or DNP (May be required if teaching at graduate level

Nursing Experience (Active RN License

Clinical Instructor
Primary role is supervising students during clinical rotations. Coordinating with clinicians at clinical sites, making student assignments, instructing students on how to perform duties in the clinical site, evaluate students' work.

Active RN License

2+ years of clinical experience

BSN (MSN or DNP Preferred)

Research Faculty
Sustain a program of research that provides their salary. Publish in peer-reviewed clinical journals, present research findings at conferences, advise students in research activities. Serve on thesis and dissertation committees. Teaching expectations are limited.

Suggested Resources:

Faculty Roles

Duffy, R. (2013). Nurse to educator? Academic roles and the formation of personal academic identities. Nurse Education Today, 33(6), 620-624. doi:10.1016/j.nedt.2012.07.020

Roberts, S. J., & Glod, C. (2013). Faculty roles: Dilemmas for the future of nursing education. Nursing Forum, 48(2), 99-105. doi:10.1111/nuf.12018

Tenure

Gaugler, J. E. (2004). on the Tenure Track in Gerontology: I Wish I Had Known Then What I Know Now. Educational Gerontology, 30(6), 517-536. doi:10.1080/03601270490445122

Singh, M. D. (2015, July). An Exploration of the Pre-Tenure and Tenure Process Experiences of Nursing Faculty. In Sigma Theta Tau International's 26th International Nursing Research Congress. STTI

Smeltzer, S. C., Sharts-Hopko, N. C., Cantrell, M. A., Heverly, M. A., Wise, N. J., Jenkinson, A., & Nthenge, S. (2014). Challenges to research productivity of doctoral program nursing faculty. Nursing Outlook, 62(4), 268-274.

Sussman, S. M. (2012). Job satisfaction and support for transitions in the nursing academy: A qualitative study of tenured nursing faculty who stay in academia (Doctoral dissertation, Teachers College, Columbia University).

Non-Tenure

Paul, P. A. (2015). Transition from novice adjunct to experienced associate degree nurse educator: A comparative qualitative approach. Teaching and Learning in Nursing, 10(1), 3-11.

Nicholes, R. H., & Dyer, J. (2012). Is eligibility for tenure possible for the doctor of nursing practice-prepared faculty?. Journal of Professional Nursing, 28(1), 13-17.

Schaar, G. L., Titzer, J. L., & Beckham, R. (2015). Onboarding New Adjunct Clinical Nursing Faculty Using a Quality and Safety Education for Nurses-Based Orientation Model. Journal of Nursing Education, 54(2), 111-115. doi:10.3928/01484834-20150120-02

Website Resources:
AACN Career Center
AACN's online resource dedicated to employment opportunities in nursing education.

HigherEd Jobs Listing of faculty positions (on-site or remote)

Education Nurses.com
Provides nursing education modules for new educators

Graduate Nursing Student Academy Career Network
Job board developed through partnership between AACN and AfterCollege.

National Council of State Board of Nursing - Nurse Licensure Compact
To determine if you live in a state included in the Nurse Licensure Compact

Professional Organizations to Consider:
It is important to maintain membership in professional associations that are tied to your area of specialization or instruction.
Association of Black Nursing Faculty National Association of Ethnic Minority Nurse Associations National Organization of Nurse Practitioner Faculties Professional Nurse Educators Group Sigma Theta Tau International The International Society of Nursing

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Creating multiple choice tests

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Cite this guide: Brame, C. (2013) Writing good multiple choice test questions. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/.

Multiple choice test questions, also known as items, can be an effective and efficient way to assess learning outcomes. Multiple choice test items have several potential advantages:

Versatility: Multiple choice test items can be written to assess various levels of learning outcomes, from basic recall to application, analysis, and evaluation. Because students are choosing from a set of potential answers, however, there are obvious limits on what can be tested with multiple choice items. For example, they are not an effective way to test students' ability to organize thoughts or articulate explanations or creative ideas.

Reliability: Reliability is defined as the degree to which a test consistently measures a learning outcome. Multiple choice test items are less susceptible to guessing than true/false questions, making them a more reliable means of assessment. The reliability is enhanced when the number of MC items focused on a single learning objective is increased. In addition, the objective scoring associated with multiple choice test items frees them from problems with scorer inconsistency that can plague scoring of essay questions.

Validity: Validity is the degree to which a test measures the learning outcomes it purports to measure. Because students can typically answer a multiple choice item much more quickly than an essay question, tests based on multiple choice items can typically focus on a relatively broad representation of course material, thus increasing the validity of the assessment.

The key to taking advantage of these strengths, however, is construction of good multiple choice items.

A multiple choice item consists of a problem, known as the stem, and a list of suggested solutions, known as alternatives. The alternatives consist of one correct or best alternative, which is the answer, and incorrect or inferior alternatives, known as distractors.

Constructing an Effective Stem

1. The stem should be meaningful by itself and should present a definite problem. A stem that presents a definite problem allows a focus on the learning outcome. A stem that does not present a clear problem, however, may test students' ability to draw inferences from vague descriptions rather serving as a more direct test of students' achievement of the learning outcome.

2. The stem should not contain irrelevant material, which can decrease the reliability and the validity of the test scores (Haldyna and Downing 1989).

3. The stem should be negatively stated only when significant learning outcomes require it. Students often have difficulty understanding items with negative phrasing (Rodriguez 1997). If a significant learning outcome requires negative phrasing, such as identification of dangerous laboratory or clinical practices, the negative element should be emphasized with italics or capitalization.

4. The stem should be a question or a partial sentence. A question stem is preferable because it allows the student to focus on answering the question rather than holding the partial sentence in working memory and sequentially completing it with each alternative (Statman 1988). The cognitive load is increased when the stem is constructed with an initial or interior blank, so this construction should be avoided.

Constructing Effective Alternatives

1. All alternatives should be plausible. The function of the incorrect alternatives is to serve as distractors,which should be selected by students who did not achieve the learning outcome but ignored by students who did achieve the learning outcome. Alternatives that are implausible don't serve as functional distractors and thus should not be used. Common student errors provide the best source of distractors.

2. Alternatives should be stated clearly and concisely. Items that are excessively wordy assess students' reading ability rather than their attainment of the learning objective

3. Alternatives should be mutually exclusive. Alternatives with overlapping content may be considered "trick" items by test-takers, excessive use of which can erode trust and respect for the testing process.

4. Alternatives should be homogenous in content. Alternatives that are heterogeneous in content can provide cues to student about the correct answer.

5. Alternatives should be free from clues about which response is correct. Sophisticated test-takers are alert to inadvertent clues to the correct answer, such differences in grammar, length, formatting, and language choice in the alternatives. It's therefore important that alternatives

have grammar consistent with the stem.

are parallel in form.

are similar in length.

use similar language (e.g., all unlike textbook language or all like textbook language).

6. The alternatives "all of the above" and "none of the above" should not be used. When "all of the above" is used as an answer, test-takers who can identify more than one alternative as correct can select the correct answer even if unsure about other alternative(s). When "none of the above" is used as an alternative, test-takers who can eliminate a single option can thereby eliminate a second option. In either case, students can use partial knowledge to arrive at a correct answer.

7. The alternatives should be presented in a logical order (e.g., alphabetical or numerical) to avoid a bias toward certain positions.

8. The number of alternatives can vary among items as long as all alternatives are plausible. Plausible alternatives serve as functional distractors, which are those chosen by students that have not achieved the objective but ignored by students that have achieved the objective. There is little difference in difficulty, discrimination, and test score reliability among items containing two, three, and four distractors.

Additional Guidelines

1. Avoid complex multiple choice items , in which some or all of the alternatives consist of different combinations of options. As with "all of the above" answers, a sophisticated test-taker can use partial knowledge to achieve a correct answer.

2. Keep the specific content of items independent of one another. Savvy test-takers can use information in one question to answer another question, reducing the validity of the test.

Considerations for Writing Multiple Choice Items that Test Higher-order Thinking

When writing multiple choice items to test higher-order thinking, design questions that focus on higher levels of cognition as defined by Bloom's taxonomy. A stem that presents a problem that requires application of course principles, analysis of a problem, or evaluation of alternatives is focused on higher-order thinking and thus tests students' ability to do such thinking. In constructing multiple choice items to test higher order thinking, it can also be helpful to design problems that require multilogical thinking, where multilogical thinking is defined as "thinking that requires knowledge of more than one fact to logically and systematically apply concepts to a ...problem" (Morrison and Free, 2001, page 20). Finally, designing alternatives that require a high level of discrimination can also contribute to multiple choice items that test higher-order thinking.

Additional Resources

Burton, Steven J., Sudweeks, Richard R., Merrill, Paul F., and Wood, Bud. How to Prepare Better Multiple Choice Test Items: Guidelines for University Faculty, 1991.

Cheung, Derek and Bucat, Robert. How can we construct good multiple-choice items? Presented at the Science and Technology Education Conference, Hong Kong, June 20-21, 2002.

Haladyna, Thomas M. Developing and validating multiple-choice test items, 2nd edition. Lawrence Erlbaum Associates, 1999.

Haladyna, Thomas M. and Downing, S. M.. Validity of a taxonomy of multiple-choice item-writing rules. Applied Measurement in Education, 2(1), 51-78, 1989.

Morrison, Susan and Free, Kathleen. Writing multiple-choice test items that promote and measure critical thinking. Journal of Nursing Education 40: 17-24, 2001.

This teaching guide is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Writing Good Multiple Choice Test Questions

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by Cynthia J. Brame Print Version Cite this guide: Brame, C. (2013) Writing good multiple choice test questions. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/. Constructing an Effective Stem Constructing Effective Alternatives Additional Guidelines for Multiple Choice Questions Considerations for Writing Multiple Choice Items that Test Higher-order Thinking Additional Resources Multiple choice test questions, also known as items,...

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The NLN's copyrighted surveys and research instruments are an important part of its research activities.

Permission for non-commercial use of surveys and research instruments (includes, theses, dissertations, and DNP projects) is granted free of charge. Available instruments may be downloaded and used by individual researchers for non-commercial use only with the retention of the NLN copyright statement. The researcher does not need to contact the NLN for specific permission. In granting permission for non-commercial use, it is understood that the following caveats will be respected by the researcher:

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View our calendar of events >

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