Rx for NCLEX-RN success: reflections on development of an effective preparation process for senior baccalaureate students.
Key Words NCLEX-RN Success--Nursing Program Outcomes Nursing Education--NCLEX Support Strategies
AN ABRUPT DECLINE IN FIRST-TIME PASS RATES ON THE NCLEX-RN [R] EXAMINATION AT A PRIVATE FOUR-YEAR COLLEGE PROMPTED FACULTY TO INSTITUTE AN EARLY, PROACTIVE RESPONSE. Through modification of senior-level course work, the use of a computerized, end-of-program examination, individualized remediation, and one-on-one interaction with students about study plans developed for NCLEX preparation, faculty have begun to realize a return to the strong first-time pass rates by which the institution has long been recognized. * For nurse graduates, passing the licensure examination validates basic competence in nursing theory and practice. More significantly, it denotes official entry into the profession. For faculty, it is the ultimate goal of their continuous engagement in the interactive process of teaching and learning with students.
Background Like peer institutions across the state of Pennsylvania and the nation, York College has experienced significant growth in nursing enrollment over the past several years. With a college student population of some 4,400 full-time undergraduates and approximately 1,500 part-time and graduate students, nursing students number nearly 550. Approximately 92 percent of these students are undergraduates working toward the baccalaureate degree: generic students, second-degree students, registered nurses (RN-BS), and practical nurses (LPN-BS).
The growing interest in the nursing program has been attributed to a number of factors, including media attention to the need for nurses, employer tuition support, and the program's good reputation. Growth in enrollment has led to larger classes and a greater student-to-faculty ratio. Faculty have less time to work with individual students to address their needs and provide positive reinforcement (Jones, 2007). Growth in enrollment has also led to greater diversity within the student body: more second-career students, more men, and, overall, a more culturally diverse group of individuals.
Not surprisingly, these changes have brought about a number of challenges. First-time NCLEX-RN pass rates, which were 90 percent or better for nearly two decades, declined to 83 percent for May 2005 graduates. This decrease may have been somewhat related to the increased passing standard that became effective in 2004, but given that the numbers reported annually by the Pennsylvania State Board of Nursing (2010) represent average performance of two subsequent graduating classes, faculty expressed significant concern. The departmental curriculum committee was charged with identifying ways to turn this trend around. A proactive approach, using the general systems theory as a conceptual framework (Giles, 1982), was seen as a way to resolve the current situation and maintain the high standards of the nursing program.
Taking Action ASSESSMENT Early assessment of the situation involved a review of the senior-year curriculum, including preparation for the NCLEX-RN examination. The curriculum committee noted that, for the preceding several semesters, NCLEX-RN review courses had been scheduled for graduates and then cancelled due to inadequate enrollment and lack of interest. This situation magnified concern among the faculty.
For many years, students had been required to take a paper-and-pencil end-of-program examination that was widely recognized as an indicator of student readiness. Despite literature indicating that combinations of performance on that particular examination, overall grade point average, and other factors were useful in predicting a graduate's chances of success on the NCLEX-RN, students reported experiencing unexpected challenges when confronted with the computerized format of the actual examination. They were now required to choose an answer for one question before proceeding to the next. They could no longer use the test-taking strategies with which they were familiar: crossing out portions of the stem that seemed unimportant, crossing out distractors to narrow the field of options, or making notations about a "best guess" with plans to return to the question later. Modification of the examination format disrupted students' sense of security (Benson & Dundis, 2003; Jones, 2007).
PLANNING/IMPLEMENTATION Early in 2004, faculty began to investigate options for computerized exit examinations. During the process, consideration of both Maslow's Hierarchy of Needs and Hertzberg's Motivational Theory (Benson & Dundis, 2003; Jones, 2007) meant that faculty sought an examination that would challenge students intellectually and offer useful feedback, yet could be administered in the nursing computer lab, an environment that provided assurance for students' safety and security needs. Helping students manage their levels of anxiety was considered essential to helping them strive toward self-actualization--passing the NCLEX-RN on the first attempt.
The committee reviewed several products, including products from companies that strongly recommended testing at every level of the program. Ultimately, a decision was made to use a computerized examination that offered 160 NCLEX-RN style questions. Based on reports in the literature with more than 11,000 students over a three-year period (Lauchner, Newman, & Britt, 1999; Newman, Britt, & Lauchner, 2000; Nibert & Young, 2001), the examination was reported to be predictive for NCLEX success. Taken during the last semester of the senior year, it was assumed that the examination would challenge students' critical thinking abilities and provide objective analysis of NCLEX-RN readiness.
After pilot testing with a small group of students during the late summer, the examination was officially administered in December 2004 to 31 students. Following a few semesters of student data and correlations with NCLEX-RN first-time pass rates, the curriculum committee members determined the standard for an acceptable score to be 850 or better. Students who did not attain that score on their first attempt would be required to engage in individualized remediation and retake the examination at their own expense at a later date. Failure to reach the goal of 850 on the second attempt led to further remedial work and a required conference with a faculty member. A statement noting these requirements was added to the syllabus of the Nursing Leadership course.
COURSE MODIFICATION Faculty determined that some course modification was in order. As a start, the Nursing Leadership course was adapted to meet the changing needs of senior students. The course had always covered a range of topics, including ethics, legal issues in nursing, conflict resolution, and change. The new goal was to strengthen the existing topics and include leadership and management theories, more discussion on delegation, cultural diversity, managed care, conflict resolution strategies, nurses as change agents, and total quality improvement and management.
Critical thinking scenarios were designed to develop and strengthen the students' problem-solving skills, enhance their ability to prioritize patient care needs, and improve their communication skills. Each assignment required students to develop specific measurable outcomes for a given scenario, to identify a means of evaluating whether or not the expected outcomes were met, and to use appropriate management or leadership theories to explain the rationale for the interventions selected. Students received individualized feedback regarding their problem-solving skills and the strategies described in the written assignment. According to the Hawthorne effect, such an approach should facilitate increased productivity and achievement (Jones, 2007).
A supplemental written assignment--a formalized individual study plan for NCLEX-RN preparation--was developed. After students took the standardized examination during their senior year, they were required to document their strengths and weaknesses based on the computerized objective analysis provided. Further, they were required to develop a realistic study plan for their own NCLEX-RN preparation.
Students' plans were expected to be unique and personal. A critical portion of the plan was the identification of barriers that students might encounter during preparation for the NCLEX-RN and development of a plan to minimize the effects of such barriers. Faculty recognized that various scenarios (e.g., loss of a study group, moving to a new area, moving back home, a new job) might have a negative effect on students' preparation. They wanted to ensure that students were prepared to acknowledge this possibility and take action to modify their study plans accordingly. By thoughtfully developing a personal study plan, students were primed to anticipate the occurrence of barriers and, more importantly, to plan an appropriate response.
In developing their study plans, students incorporated study skills that had proven effective throughout their college years. They designed plans that would work for them. Bonis, Taft, and Wendler (2007) and Frith, Sewell, and Clark (2006) associated this type of strategy with positive outcomes on the NCLEX-RN.
Following submission of the study plan, Nursing Leadership faculty provided individualized feedback, in writing, and a grade based on the quality and insightfulness of the overall plan. They offered recommendations on how to overcome identified barriers and suggestions for modifying study techniques. The time spent in providing personalized feedback offered students the opportunity for more one-on-one interaction with faculty, something considered important according to the Hawthorne effect (Jones, 2007). As Bain (2004) stated, effective teachers invest in their students.
INDIVIDUALIZED CONFERENCES Students who were unable to achieve a score of 850 on the second examination were required to meet individually with faculty prior to graduation. The purpose of this conference was to emphasize the importance of preparation for the NCLEX-RN examination and to encourage the student to take responsibility for the study plan. Conferences were interactive. Faculty listened and gave advice based on the individual's situation and needs regarding study tips, effective test-taking strategies, and NCLEX-RN reviews.
Evaluation of Outcomes The proactive approach described in this article has already yielded measurable outcomes in the form of improved first-time pass rates on the licensure examination. Ninety-one percent of graduates passed the exam on the first attempt between October 2005 and September 2006; 94 percent passed between October 2006 and September 2007; 91 percent passed between October 2007 and September 2008; and 94.9 percent passed between October 2008 and September 2009. The graduate nurse's ability to pass the NCLEX-RN examination on the first attempt promotes self-confidence, supports self-esteem, and represents the achievement of a critical personal goal. While faculty are pleased with the results to date and continue to monitor NCLEX-RN pass rates each semester, other pieces of the puzzle may still require attention. Course content adjustments are made to adapt to changing needs for nursing education based on documentation of best practices, new technologies, and the needs of students. Therefore, this remains a work in progress.
About the Authors Karen S. March, PhD, RN, is a professor of nursing, and Janice M. Ambrose, MS, RN, is an adjunct assistant professor of nursing, York College of Pennsylvania, York. Contact Dr. March at firstname.lastname@example.org.
Bain, K. (2004). What the best college teachers do. Cambridge, Mass: Harvard University Press.
Benson, S., & Dundis, S. (2003). Understanding and motivating health care employees: Integrating Maslow's hierarchy of needs, training and technology. Journal of Nursing Management, I I, 315320.
Bonis, S., Taft, L., & Wendler, M. (2007). Strategies to promote success on the NCLEX-RN[R]:An evidence-based approach using the ACE Star Model of Knowledge Transformation. Nursing Education Perspectives, 28(2), 82-87.
Frith, K., Sewell, J., & Clark, D. (2006). Best practices in NCLEX readiness preparation for baccalaureate student success. Nurse Educator, 33(5) (Suppl.), 46S-53S.
Giles, D.A. (1982). Nursing management: A systems approach. Philadelphia: W.B. Saunders.
Jones, R. (2007). Nursing leadership and management: Theories, processes and practice. Philadelphia: F.A. Davis.
Lauchner, K., Newman, M., & Britt, R. (1999). Predicting licensure success with a computerized comprehensive nursing exam: The HESI exit exam. Computers in Nursing, 17, 243-46.
Newman, M., Britt, R., & Lauchner, K. (2000). Predictive accuracy of the HESI exit exam: A follow-up study. Computers in Nursing, 18, 132-136.
Nibert, A., & Young, A. (200 I). Predicting NCLEX success with the HESI exit exam: A third study. Computers in Nursing, 19, 172-178.
Pennsylvania State Board of Nursing. (2010). NCLEX-RN performance of first time candidates educated in Pennsylvania who completed NCLEX in the U.S. Retrieved May 28, 2010, from www.portal.state.pa.us/portal/server.pt?open=5 I 4&objlD=572050&mode=2
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|Title Annotation:||NCLEX PREPARATION; National Council Licensure Examination|
|Author:||March, Karen S.; Ambrose, Janice M.|
|Publication:||Nursing Education Perspectives|
|Date:||Jul 1, 2010|
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