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After completion of our highly successful iNICQ focused on Neonatal Abstinence Syndrome (NAS) VON is now continuing the quest to improve care for substance-exposed infants and families, through the launch of two new resources.

NAS Universal Training Education Package - available for individuals, centers, or health systems focused on harnessing the power of universal training and standardizing NAS care.read more

These resources include:

NAS Universal Training Program - including 18 critical Micro-Lessons relevant to every caregiver who provides care to substance-exposed infants and women, and presented by 35 world-class NAS experts - available 24/7 on-line with CME, CNE pharm-eligible credits.

A VON Improving NAS Toolkit.

A 5-Chapter Virtual Video Visit and Facilitators Guide, to a Center of Excellence in NAS Care - highlighting the trauma-informed approach to care that has yielded tremendous success in other settings.

Sample policies, procedures, guidelines and family educational tools essential for NAS Care.

Over 100 NAS-related quality improvement stories, and data - showing real-world examples of measurable improvement in length of stay, length of treatment and cost - while improving satisfaction.

NAS Statewide / Health System Implementation Package - now available to Statewide Perinatal Quality Improvement Collaboratives, health systems, hospitals and individuals will benefit from the enduring value of this educational program available on demand on VON's Learning Management System. Investment in this collaborative was likely cost-saving for states that supported center engagement. Using 2012 approximations, we estimated that reducing the hospital LOS by 2 days nationwide would result in a savings of a projected $170 million in hospital charges. Click here for more details on statewide programs.

Background - Understanding NAS and the Opioid Epidemic

Every 25 minutes an opioid-exposed infant is born at risk for neonatal abstinence syndrome (NAS). Many NICUs, step-down units, and newborn nurseries are struggling to care for this medically fragile and socially complex population. read more

Over the last decade, the number of prescriptions written for opioids grew substantially. According to the Centers for Disease Control and Prevention, in 2012, an estimated 259 million prescriptions were written in the United States, enough for every American adult to have one bottle of pills. As more Americans used opioids, complications such as adult overdose deaths and NAS increased.

Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by infants exposed to opioids, or narcotic drugs like oxycodone, while in utero. NAS has been linked to both illicit drug use as well as prescription opioids - narcotic pain relievers such as hydrocodone - by pregnant women. Infants born with NAS are more likely to have respiratory complications, feeding difficulty, low birthweights, and extended hospital stays.

What is NAS Universal Training?

Providing high-reliability care requires developing standardized clinical processes. Universal educational programs apply the principle of standardization to education. The power of universal educational programs, such as NRP and others, is that the training provides a solid foundation upon which to standardize care.

What Are the Components of the NAS State Implementation Package?

The VON designed and tested NAS Universal Training Program includes state-of-the art evidence-based content from leading experts in NAS care, including the author of the AAP Guidelines, Dr. Mark Hudak, and 35 of the leading worldwide experts in neonatal care. read more

By subscribing to the NAS Universal Training Program your center, health system, or state will be able to provide access to critical education and improvement tools to every provider! These resources include:

NAS Universal Training Program - including 18 critical Micro-lessons relevant to every caregiver who provides care to substance-exposed infants and women, and presented by 35 world-class NAS experts - available 24/7 on-line with CME, CNE pharm-eligible credits.

A customizable VON Improving NAS Toolkit - ready for your team to add the state specific context, branding and key statewide AIMS for improving NAS care.

A 5-Chapter Virtual Video Visit and Facilitators Guide, to a Center of Excellence in NAS Care - highlighting the trauma-informed approach to care that has yielded tremendous success in other settings.

Statewide Data and Reporting - Statewide perinatal collaboratives may elect to use the VON Day Quality Audits for NAS. This data reported at the center and state level, will provide a useful gap analysis and benchmarks to inform statewide improvement efforts and track progress throughout your improvement cycle.

Sample policies, procedures, guidelines and family educational tools essential for NAS Care.

Over 100 NAS-related quality improvement stories, and data - showing real-world examples of measurable improvement in length of stay, length of treatment and cost - while improving satisfaction.

What Results Have the 200+ VON Centers Achieved?

Prompted by the alarming statistics the American Academy of Pediatrics released a policy statement in 2012, calling for standardizing care for infants with NAS. That same year, Vermont Oxford Network, a non-profit dedicated to improving the quality and safety of medical care for infants and their families, launched the multi-center quality improvement collaborative focused on rapid-cycle adoption of these important practice guidelines. read more

Since 2013, over 200 leading teams from VON have been focused on systematically implementing the AAP guidelines for the care of infants and families affected by NAS. Working collaboratively these teams have made major strides in standardizing practice by adopting evidence-based policies and developing innovative service models for mothers and infants across the trajectory of care. In 2015, 110 centers including five statewide quality improvement collaboratives focused on adopting the VON Universal Training Solution for NAS in an effort to deliver highly reliable care to every patient, every time. The five statewide collaboratives are:

Alaska - Alaska State Collaborative - State Leader: Lily Lou MD

Massachusetts - Neonatology Quality Improvement Collaborative (NeoQIC) - State Leaders: Munish Gupta MD & Alan Picarillo MD

Michigan - Michigan Collaborative Quality Initiative (MICQI) - State Leader Padu Karna MD

New Hampshire/Vermont - Northern New England Perinatal Quality Improvement Network (NNEPQIN) State Leaders: William Edwards MD, Victoria Flanagan RN & Bonny Whalen MD

Wisconsin - Wisconsin Neonatal Perinatal Quality Collaborative (WINpqc) State Leaders: Sue Kannenberg RHIA, Jeff Garland MD & Janice Ancona MSN, RN

To date, 45 centers have achieved the VON Center of Excellence in NAS Education and Training Designation. Click here for a list of these centers.

VON Published Results - Pediatrics 2016

The initial results of the VON Quality Improvement effort are published in the following paper:

Patrick SW, Schumacher RE, Horbar JD, Buus-Frank ME, Edwards EM, Morrow KA, Ferrelli KR, Picarillo AP, Gupta M, Soll RF. Improving care for neonatal abstinence syndrome. Pediatrics. 2016; 137(5): e20153835. PubMed: 27244809

"Many of the hospitals implemented simple and inexpensive strategies, such as swaddling, soothing, skin-to-skin contact with mothers and breastfeeding to prevent escalation of withdrawal symptoms in the first few days after birth. This translated into decreased use of additional narcotics and sedatives to control withdrawal symptoms, and avoided the need for costly admission to a newborn intensive care unit," said Madge Buus-Frank, DNP, Executive Vice President and Director of Quality Improvement and Education at Vermont Oxford Network.

The evidence of better outcomes, the study authors conclude, reinforces the need to continue to standardize the care provided to infants with NAS and to explore ways to make care more efficient and family centered.

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After completion of our highly successful iNICQ focused on Neonatal Abstinence Syndrome (NAS) VON is now continuing the quest to improve care for substance-exposed infants and families, through the launch of two new resources.

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On April 1, 2009, the National Commission for Certifying Agencies (NCCA) granted accreditation to the NLN's CNE Program for demonstrating compliance with the NCCA Standards for the Accreditation of Certification Programs. NCCA is the accrediting body of the National Organization for Competency Assurance (NOCA). The NCCA Standards were created in 1977 and updated in 2003 to ensure certification programs adhere to modern standards of practice for the certification industry. The NCCA certification was renewed in 2014.

CNE Renewal Applicants 2017 and 2018
Due to multiple events occurring at the same time, the CNE program is behind in the processing of CNE renewals. The manual process needing to be done at this time is a very time-consuming laborious process, resulting in a long delay in renewal processing and a backlog of renewal applications. Please bear with us and we make alternative plans to get through this difficult time. We appreciate you as a CNE and I heartily apologize for this inconvenience.

The Certified Nurse EducatorCM (CNE) Examination

The Value of Certification

Certification in any field is a mark of professionalism. For academic nurse educators, it establishes nursing education as a specialty area of practice and creates a means for faculty to demonstrate their expertise in this role. It communicates to students, peers, and the academic and health care communities that the highest standards of excellence are being met. By becoming credentialed as a Certified Nurse Educator (CNE), you serve as a leader and a role model.

Mission Statement

The mission of the Academic Nurse Educator Certification Program is to promote excellence in the advanced specialty role of the academic nurse educator.

Goals of CNE Certification:

Distinguish academic nursing education as a specialty area of practice and an advanced practice role within professional nursing

Recognize the academic nurse educator's specialized knowledge, skills, and abilities and excellence in practice

Strengthen the use of core competencies of nurse educator practice

Contribute to nurse educators' professional development

If you are interested in having your expertise as an academic nurse educator recognized and valued, please click on the links to the left and learn how to become a Certified Nurse Educator.

If you notice omissions or have additional questions, please contact us via email at certification@nln.org.
Certification - The Mark of Distinction for Nursing Faculty

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On April 1, 2009, the National Commission for Certifying Agencies (NCCA) granted accreditation to the NLN's CNE Program for demonstrating compliance with the NCCA Standards for the Accreditation of Certification Programs. NCCA is the accrediting body of the National Organization for Competency Assurance (NOCA).

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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,...