Key takeaways
●The Next Generation NCLEX (NGN) now tests clinical reasoning, not recall, and the resulting drop in NCLEX-RN first-time pass rates in 2025 to 86.7% shows most programs haven't yet built the infrastructure to develop that reasoning at scale (NCSBN, 2025).
●Evidence points to frequency, not fidelity, as the lever that builds clinical judgment. One or two exposures are generally insufficient to move the needle on clinical judgment (Klenke-Borgman et al., 2020). The NCSBN's landmark National Simulation Study provided guidance on supporting substitution of 50% of clinical hours with high quality simulation (Hayden et al., 2014). Nursing programs can't close the gap by adding clinical hours. Faculty vacancies sit at 7.2% nationally, and a persistent pay gap against clinical roles keeps experienced nurses out of teaching, making the capacity constraint structural, not temporary (AACN, 2025, 2026).
●The fix isn't more content or more clinical time. It's giving every student in a cohort standardized, repeatable practice without creating additional workload for faculty.
●DDx by Sketchy is entering undergraduate nursing to do exactly that: better prepare nursing students for clinical practice by extending faculty capacity rather than add to it.
First-time NCLEX-RN pass rates for U.S.-educated candidates fell to 86.7% in 2025, down from 91.2% in 2024: the steepest single-year decline since the NGN redesign took effect in 2023 (NCSBN, 2025). The readiness signal isn't limited to the exam. A 2025 survey of 390 hospital and health-system hiring leaders found that 65% say it's harder to find practice-ready graduates than three years ago, and only 17% believe today's nursing programs fully prepare students for current hospital needs. Closing that gap doesn't require more clinical hours, since most programs don't have any to add. It requires more frequent, standardized practice applying judgment to realistic scenarios, delivered in a way that doesn't add to an already overextended faculty's workload.
Why did NCLEX pass rates decline in 2025?
The 2025 numbers mark the first drop since the NGN launched in April 2023, when the National Council of State Boards of Nursing (NCSBN) redesigned the exam around its Clinical Judgment Measurement Model (CJMM), a six-step framework that requires candidates to recognize cues, analyze information, prioritize hypotheses, generate solutions, take action, and evaluate outcomes, rather than simply recall facts (NCSBN, 2024). The overall pass rate, which includes repeat test-takers, fell further still, to 69.1% from 73.3% the year before (NCSBN, 2025).
Some of the decline in overall pass rates may reflect changes in the composition of the testing population, including a growing proportion of internationally educated candidates, who historically have lower first-time pass rates. For nursing programs, however, the first-time pass rate among U.S.-educated candidates provides a more relevant measure of graduate performance. The decline in this group following the higher pass rates seen in 2024 raises an important question: whether those earlier gains represented a sustained improvement or an initial adjustment to the NGN.
The larger issue extends beyond the licensing examination. The NGN places greater emphasis on students’ ability to apply knowledge and make clinical judgments in complex patient situations. Employer data suggest a similar challenge after graduation, with nearly two-thirds of hiring leaders reporting that new graduates possess foundational knowledge but struggle to apply it effectively in unpredictable clinical situations. Viewed together, these findings point to a common challenge for nursing education: students need not only to know the content but also repeated opportunities to practice applying that knowledge when patient conditions, priorities, and decisions are less predictable.
What actually builds clinical judgment in nursing students?
The research on this question is fairly consistent: clinical judgment develops through repeated, standardized practice, not through a single simulation-based event or more content review.
Research suggests that repeated screen-based simulation may help students strengthen specific clinical decision-making skills. In a study of 68 prelicensure nursing students enrolled in an adult medical-surgical course, Fogg et al. (2023) integrated two multiple-patient, prioritization-of-care simulations across one semester. By the second simulation, students demonstrated improvements in selecting and prioritizing appropriate interventions while also completing the experience in less time. Although results varied across other measures of clinical decision-making, the findings support the value of giving students repeated opportunities to practice managing multiple patients and competing priorities in a simulated environment. This emphasis on repeated practice is also reflected in a broader review of 24 high-fidelity simulation studies, which identified the number of simulation exposures as an important factor influencing learning outcomes and one that nursing programs can intentionally build into their curricula (Klenke-Borgmann et al., 2020).
The format of practice matters less than the frequency and consistency of it. A student who works through five realistic patient encounters across a semester is more likely to internalize the reasoning process of the NGN tests than a student who works through one elaborate simulation and several chapters of review questions.
Why can't nursing programs just add more clinical hours?
The instinctive response to a readiness gap is to add exposure: more clinical hours, more placements, more faculty-led simulation. For most programs, none of that is available to add.
The American Association of Colleges of Nursing reported in May 2026 that U.S. nursing schools turned away 93,176 qualified applicants in the 2025–2026 academic year, an increase of nearly 30,000 in just two years (AACN, 2026). These weren't students who failed to qualify. They met every admission requirement and were turned away because programs lacked the faculty, clinical sites, or classroom capacity to teach them.
That capacity problem starts with faculty. AACN's October 2025 survey identified 1,588 full-time faculty vacancies across 1,075 nursing schools, a 7.2% national vacancy rate (AACN, 2025). Nursing faculty typically earn 20 to 30% less than clinical roles, with the gap between nurse practitioner and CRNA salaries often exceeding $40,000 a year, a structural disincentive that keeps experienced nurses at the bedside rather than in the classroom. Add in a wave of expected faculty retirements, and the constraint isn't a temporary staffing dip. It's a durable ceiling on how much clinical exposure any given cohort can realistically receive from current faculty.
The practical consequence is uneven exposure. Clinical placement is scarce and inconsistent, so students in the same cohort can graduate having encountered very different high-stakes scenarios. Programs need a way to guarantee every student practices the scenarios that matter most, without asking already-stretched faculty to design, run, and debrief more simulation hours themselves.
More practice for students. Not more work for faculty.
Nurse educators know the challenge: students need repeated opportunities to practice clinical judgment, but faculty time is already stretched. Traditional simulation helps by allowing faculty to create standardized learning experiences for multiple students. But what if that same idea could extend beyond the simulation lab, giving every student in a cohort more opportunities to practice without adding more simulations to build, facilitate, or grade? That is where asynchronous, AI-enabled practice offers an intriguing possibility.
DDx by Sketchy brings this approach to prelicensure nursing education through structured, realistic patient encounters that allow students to practice clinical reasoning, communication, and technical skills on their own time. The experiences align with the clinical judgment process measured by the NGN, while shifting faculty time away from routine facilitation and grading and toward the coaching and guidance only faculty can provide. In our September webinar, we’ll explore how DDx by Sketchy can fit within ADN and BSN curricula and share early perspectives from nurse educators who have reviewed the platform. If your program is looking for ways to strengthen clinical judgment without adding to faculty workload, this is a conversation worth joining.
Register for the September webinar on building clinical judgment in prelicensure nursing programs: educators.sketchy.com/webinars
Frequently asked questions
Why did NCLEX-RN pass rates drop in 2025? NCLEX-RN pass rates dropped in 2025 because the exam, redesigned around the NCSBN's CJMM in 2023, increasingly tests reasoning rather than recall, and many programs are still adjusting their curricula to consistently develop that reasoning. First-time, U.S.-educated pass rates fell from 91.2% in 2024 to 86.7% in 2025 (NCSBN, 2025).
Why can't nursing schools just add more clinical hours to close the readiness gap? Nursing schools can't easily add clinical hours because faculty and clinical placement capacity are already at their limit. AACN reported a 7.2% national faculty vacancy rate in 2025 and 93,176 qualified applicants turned away in 2025–2026 due to insufficient faculty, clinical sites, and classroom space.
How much clinical time can simulation actually replace? NCSBN's landmark National Simulation Study found that substituting up to 50% of traditional clinical hours with high-quality, standardized simulation did not compromise student competency or NCLEX outcomes. Based on that research, NCSBN published national guidelines recommending 50% as a benchmark, and most state boards of nursing have since adopted that threshold, though the exact limit still varies by state.
What is DDx by Sketchy? DDx by Sketchy is an AI-enabled clinical readiness platform that gives learners structured, multi-role case simulation across clinical reasoning, communications, and technical skills. In undergraduate nursing, it's designed to extend faculty capacity by giving every student in a cohort standardized, asynchronous practice with realistic patient encounters.
Sources
- American Association of Colleges of Nursing. (2026). Nursing shortage fact sheet. https://www.aacnnursing.org/Portals/0/PDFs/Fact-Sheets/Nursing-Shortage-Factsheet.pdf
- American Association of Colleges of Nursing. (2025). Faculty shortage fact sheet [Special survey on vacant faculty positions]. https://www.aacnnursing.org/Portals/0/PDFs/Fact-Sheets/Faculty-Shortage-Factsheet.pdf
- Fogg, N., Yousef, M. G., Thompson, A. W., Bauman, E. B., & Kardong-Edgren, S. (2023). Fostering clinical decision-making using screen-based simulations aligned with the NCSBN Clinical Judgment Measurement Model. Clinical Simulation in Nursing, 84, 101452. https://doi.org/10.1016/j.ecns.2023.101452
- Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jefferies, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), Suppl.
- Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educators' guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215–221. https://doi.org/10.1097/01.NEP.0000000000000669
- National Council of State Boards of Nursing. (2024). Clinical judgment measurement model. https://www.nclex.com/clinical-judgment-measurement-model.page
- National Council of State Boards of Nursing. (2025). NCLEX pass rates [2025 examination statistics].
- Survey of hospital and health-system hiring leaders on new-graduate nurse readiness (August 2025, N = 390, 95% confidence, plus or minus 5% margin of error).
