Someone wrote the exam that determines whether you pass your nursing course. Maybe they wrote it the week before you took it, between clinical placements and committee meetings, while teaching full time. Maybe they pulled it from a textbook test bank and updated a few answers. Maybe a contractor wrote it for a company you've never heard of, and a nurse educator you'll never meet reviewed it for an hour before it went to press.

Maybe an AI generated the first draft.

You have the right to know how this works. Not to be cynical about your education, but because understanding the landscape changes how you prepare for every assessment between here and the NCLEX.

Here is the full picture, from one end of the spectrum to the other.

The Individual Faculty Member

Most nursing students never think about who writes their course exams. The honest answer, for many programs, is a single faculty member working alone.

According to published data, a well-constructed multiple-choice nursing exam item takes an average of 30 minutes to one hour to write. That timeline assumes the writer has formal training in item construction, understands Bloom's taxonomy, can write a plausible stem, and can create four answer choices where only one is defensible and the other three reflect real clinical errors, not obvious distractors. Research indicates that a typical nurse educator writes three to five exams per didactic course per semester. If that educator teaches three courses, they may write up to fifteen unique tests in a single term.

Only 60% of nursing faculty report receiving formal training in NCLEX-style item writing. Thirty-seven percent learned on their own.

This is not a character critique. Nursing faculty are among the most overextended professionals in higher education. They are managing clinical placements, running simulation labs, serving on accreditation committees, and trying to keep up with a test plan that NCSBN revises every three years. Item writing is one task among dozens. And yet for many students, a faculty-authored exam is the primary mechanism determining whether they progress.

Research on nursing curriculum MCQs found item-writing flaws in 46.2% of questions. A separate study in professional education found that flawed items can lead to misclassification of 10 to 15% of students as failing when their actual knowledge would have produced a passing result. Those are not small numbers when the stakes are a student's seat in a nursing program.

The Textbook Test Bank Shortcut

When writing original questions from scratch is not feasible, many faculty turn to test banks that accompany nursing textbooks. A national survey found that 32% of faculty with five or more years of experience modify test bank questions rather than writing their own.

The problems with this approach compound. Test bank questions are written by different contractors than the faculty using them, and their alignment to a specific course's learning objectives is assumed rather than verified. The questions may have been validated for a different curriculum context. Security is consistently identified as a concern: test banks are widely circulated, and in programs where the same bank is used across multiple semesters, students sometimes access prior versions.

Research on this practice is direct: test bank questions "frequently contain flaws, and specific evidence-based methods for modifying these items are lacking." Faculty who modify rather than replace flawed items often inherit the flaw along with the question.

Large Institution Item Banks

Some larger nursing programs and multi-campus university systems have developed a different model: a dedicated team of nurse educators whose primary function is writing and maintaining a shared item bank used across all sections and campuses.

This is better. It distributes the labor, allows for systematic review, creates consistency across instructors, and enables item analysis over time. A question that is consistently missed by high-performing students and passed by struggling ones is flagged and revised. Items are reviewed against the current NCLEX test plan before each semester.

This model requires resources most programs do not have: dedicated staff, psychometric support, time, and institutional commitment to treating assessment as a function that deserves the same investment as curriculum development. Programs with this infrastructure tend to produce more reliable exams. They also tend to be the same programs with stronger NCLEX outcomes.

The Commercial Vendor Pool

Then there is the commercial ecosystem: ATI, HESI, Kaplan, and a network of smaller test prep and assessment companies.

These companies describe their item writers as master's- and doctorate-prepared nurse educators with content-specific expertise. That is accurate as far as it goes. What the marketing language does not describe is the contract structure. Commercial test companies typically hire nurse educators on a part-time, as-needed basis to develop content. ATI's own job postings describe virtual nurse educator positions that are "hired on an as-needed basis." Their clinical judgment content blog describes using "a strong network of diverse external experts who develop creative and original content."

In practice, this means a relatively small pool of nurse educators writes for multiple companies. Someone who contracts with one company for pharmacology content may be writing for another simultaneously. An educator who helps develop ATI modules may also review content for a different platform. Editorial oversight is lean by necessity. One or two senior editors review large volumes of items across many clinical categories.

This is not a scandal. It is a structural reality of how these companies operate at scale. But it is worth naming, because it means the "independent" assessment landscape is not as independently developed as the separate brand names suggest.

ATI has now introduced Claire AI, an artificial intelligence tool that generates draft test items for nurse educators. Their 2024 blog post positions this as a faculty burden solution, noting that 55.8% of faculty who left academia cited assessment creation as a top concern. AI-generated items reviewed by one editor before entering a student's graded exam represent a new category in this spectrum entirely.

The Standard That Governs the NCLEX

At the other end of the spectrum is NCSBN.

The NCLEX item development process begins with a practice analysis: a large-scale survey of thousands of newly licensed nurses across the United States, conducted every three years, identifying which tasks entry-level nurses actually perform and how critical those tasks are to patient safety. That survey directly shapes the test plan.

Item writing panels consist of nurses from every NCSBN jurisdiction, selected for clinical and educational expertise. Every item is statistically pretested before entering the active bank. Every item in the bank is reviewed for currency and accuracy every four years. The test plan is approved by the Delegate Assembly, the governing body of state boards of nursing. Independent psychometricians verify the science at every stage.

The result is an exam that is legally defensible, psychometrically sound, and anchored in verified nursing practice. It is also an exam that took years and thousands of participants to build.

What This Means for How You Prepare

The NCLEX you will take after graduation was built by a multi-year, multi-stakeholder process grounded in actual nursing practice data.

None of this means your course exams are unfair, your faculty are incompetent, or commercial tools are useless. Most faculty are doing their best under impossible conditions. Most commercial items are written by genuinely qualified people.

What it means is that the content standard governing every one of these assessments is ultimately the same: the NCLEX test plan. The closer your preparation is to that standard, the better prepared you are for every exam in the sequence.

Understanding the system does not excuse it. But it does tell you where to aim.

NCLEX Mastery is built around the NCLEX test plan, not around any vendor's interpretation of it. Adaptive practice, clinical judgment formats, and a study engine aligned to how the actual exam works. More than 27 million students have used it. Pass or we pay you.

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Source notes for editors:

• 30 minutes to 1 hour per item; 3-5 exams per course per semester; up to 15 exams per term: ATI Nursing Education blog, April 2025, atitesting.com/educator/blog/knowledge/2025/04/09/meeting-the-challenges-of-exam-development-with-artificial-intelligence

• 60% trained / 37% self-taught; 46% write own questions; 32% use modified test banks: Nurse Educator journal, "Faculty Development Needs and Approaches to Support Course Examinations," 2024, journals.lww.com

• 46.2% item-writing flaw rate in nursing curriculum MCQs: Tarrant et al., cited in multiple peer-reviewed sources

• 10-15% misclassification rate from flawed items: Downing, cited in PMC4982015

• 55.8% of exiting faculty cited assessment creation as top concern; ATI part-time "as needed" hiring: ATI blog April 2024 and Ascend Learning job postings

• Claire AI for item generation: ATI LinkedIn / blog, 2024-2025

• NCSBN practice analysis and item development process: ncsbn.org/exams/exam-statistics-and-publications/practice-analyses.page; nclex.com/faqs.page

• "network of diverse external experts": ATI clinical judgment assessment blog, atitesting.com/educator/blog/knowledge/2022/06/28/assessing-clinical-judgment