Improving NCLEX First-Time Pass Rates: A Comprehensive Program ...

Improving NCLEX First-Time Pass Rates: A Comprehensive Program Approach Joanne Farley Serembus, EdD, RN, CNE For nursing schools to retain accreditation, their students must achieve a benchmark first-time pass rate on the NCLEX-RN® and NCLEX-PN® examinations. Because the NCLEX test is updated periodically, based on a practice analysis conducted every 3 years, and due to increasing required benchmark pass rates, nurse educators are challenged to meet these standards. One evidence-based method, a continuous improvement plan, can help education programs achieve success. This approach provides a way to assess and improve a program from the admission period through program progression to graduation. This article describes such a program and its benefits.

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or accreditation from the Commission on Collegiate Nursing Education (2013, p. 18) and the National League for Nursing Commission for Nursing Education Accreditation (2015), the current benchmark for the NCLEX-RN® and NCLEX-PN® examinations is an average firsttime pass rate of 80% over the most recent 3 years. Accreditation bodies set this benchmark as being representative of program effectiveness in fulfilling the program’s mission and goals. While various state boards of nursing (BONs) may require a first-time pass rate of 80% on the NCLEX examination, states differ on whether and how a set benchmark is applied. BONs set benchmarks for the first-time pass rate to ensure public safety and safe standards of nursing practice (National Council of State Boards of Nursing [NCSBN], 2013, 2014). In some states, a nursing education program must achieve and maintain a minimum pass rate of 80% or more of its first-time examinees annually. If this is not achieved, the school of nursing is placed on provisional status and has a set time (e.g., 2 years) to correct deficiencies. Schools can be in danger of losing approval from their BON if the firsttime pass rate is not achieved. In conjunction with changes in the pass rates and/or the test plan, national first-time pass rates often drop (Harding, 2010; Morrison, 2005; Wendt & Kenny, 2007). As Table 1 shows, these rates usually recover over the next 2 years. A number of studies discuss strategies for increasing NCLEX pass rates, including revising admission standards and progression and remediation policies (Morrison, Free, & Newman, 2002; Schooley & Kuhn, 2013; Spurlock & Hanks, 2004). Such factors as gender, ethnicity, test anxiety, timing of NCLEX completion, critical-thinking ability, and course grades have all been investigated as causes of first-time examination failures (Taylor, Loftin, & Reyes, 2014). Researchers, however, have not been able to identify a single strategy that reliably contributes to NCLEX success.

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Journal of Nursing Regulation

To graduate competent nurses, schools of nursing need a comprehensive approach to program evaluation. A comprehensive and continuous approach takes into account all program input and output. It allows for a critical appraisal of the educational endeavor along with formation of workable solutions. This article focuses on a plan for continuous assessment and improvement reinforced by evidence-based research for improving and maintaining program quality and increasing NCLEX first-time pass rates as the final outcome.

Continuous Improvement Plan Using a continuous improvement plan (CIP) is central to program evaluation. Deming’s continuous improvement model is based on general systems theory (Deming, 1986, 1994). Originally used in management, Deming’s doctrine of generating quality by building it into the process, rather than by inspecting defects in the end product, has been revolutionary. Deming demands a total transformation rather than incremental improvements. Rather than dwelling on individual causes of variation and searching for errors caused by individual workers, Deming emphasizes the removal of common causes of variation by improving the system. Deming’s continuous improvement model has four phases: Plan, Do, Study, Act. These phases represent a continuous cycle of activities with a feedback loop. (See Table 2.) The plan outlined in this article was instituted at a baccalaureate (BSN) nursing program and a diploma nursing program in response to a decrease in NCLEX-RN pass rates as well as lower-than-expected scores on comprehensive standardized examinations. Rather than investigating these data as a defect, the faculty in both nursing programs decided to view them as a variance that required a closer look at the educational system—one that required a large-scale change. One year after implementation of the CIP, the first-time pass rate for the BSN students from a private urban school of

TABLE 1

NCLEX First-Time Pass Rates This table shows the NCLEX first-time pass rates for the years 2000 through 2015. The pass rates in bold indicate the years that the NCLEX test plan or passing standard was changed. Note the general tendency for rates to drop in the year of change and then recover over the next 2 years. Pass Rates (%) Program

2015* 2014

Diploma

86.84 83.28 83.42 91.18 89.76 89.66 90.75 87.5

2013

2012

2011

2010

2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 87.9

89.5

90.3

88.2

89.8

86.3

86.2

83.4

Baccalaureate degree 88.04 84.93 85.18 91.66 89.09 88.69 89.49 87.5

86.4

88.3

86.7

84.8

86.9

86.7

85.9

83.9

Associate degree

83.30 79.26 81.43 89.32 86.99 86.46 87.61 86.2

84.8

88.0

87.5

85.3

87.0

86.7

85.3

83.8

Licensed practical nurse certification

82.14 82.16 84.63 84.23 84.83 87.05 85.72 85.6

87.3

87.9

89.1

89.4

88.2

86.5

86.4

85.0

Note. Rates obtained from the National Council of State Boards of Nursing data on Exam Statistics & Publications at www.ncsbn.org/exam-statisticsand-publications.htm. Rates are calculated based on US-educated candidates. *2015 pass rates include all but the last quarter (Oct-Dec), which was not yet available at time of publication.

nursing increased from 73% to 96% and remained in the 90% range for the length of the CIP, which was 3 years. The number of graduates per year was 65 to 70; 98% were female and traditional college students. The first-time pass rate for the diploma students in an urban hospital school of nursing increased from 83% to 90% in 1 year, which was the highest first-time pass rate in 5 years. The first-time pass rate of the school remained at 93% to 100% until 2012. The number of graduates per year was 60 to 65; 95% were female and nontraditional adult learners. The CIP was implemented in both the BSN and diploma programs in response to a decrease in end-of-program comprehensive standardized examination scores as well as NCLEX-RN first-time pass rates. The Mosby Assess Test was used as an endof-program examination in the BSN program and the HESI Exam was administered at the end of the diploma nursing program. No other standardized examinations were offered prior to the institution of the CIP. In this way, the outcome for the same time period was compared. Applying Plan-Do-Study-Act

In the Plan phase of the CIP, a strategy for improving NCLEX pass rates is established. The development of this plan was designed by the director of both the BSN and diploma programs with the input of faculty members. In keeping with Deming’s theories, buy-in is essential for the success of a CIP (Deming, 1994). This plan extends from the admission period throughout progression in the program to graduation and success on the NCLEX. (See Figure 1.) Development is based on the results of past student program outcomes. During the Do phase of the CIP, the plan is rolled out, and strategies are enacted. Careful evaluation of the results of the plan is conducted during the Study phase. The Act phase calls on the educator to accept or reject the plan depending on the outcomes. If success is achieved, the strategies are impleVolume 6/Issue 4 January 2016

mented and continue to be assessed. If the outcomes are negative, the plan phase of the cycle is reentered, and a new approach to the problem is identified (Holt, 1993). Admission Standards

Investigating a program’s admission standards is the first step in considering factors contributing to the NCLEX pass rate. Amending these standards requires a delicate balance. Raising admission standards will decrease the number of accepted applicants; decreasing standards may result in the graduation of illprepared, unsafe nurses, resulting in errors regarding patient care and increased health care costs. A number of admission criteria have been used to predict student success in the academic program and on the NCLEX, including ⦁ Overall score on the Scholastic Aptitude Test (SAT) ⦁ Verbal SAT score ⦁ Math SAT score ⦁ American College Testing (ACT) examination scores ⦁ Prenursing grade point average (GPA) ⦁ Prenursing science GPA ⦁ Critical-thinking scores. Tests developed as nursing program entry examinations include: ⦁ Health Education System Incorporated Admission Examination (HESI A2 Exam) ⦁ Test of Academic Skills (ATI TEAS) ⦁ Educational Resources Inc. (ERI) test ⦁ National League for Nursing Pre-Admission Test (NLN PAX) ⦁ Educational Resources Inc. Nurse Entrance Test (NET) ⦁ Kaplan Pre-Nursing Test. Many nonacademic variables are either difficult to measure or are not amenable to change and therefore are not included in this discussion. www.journalofnursingregulation.com

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Science GPA was found to be the most consistent predictor of program and NCLEX-RN success in the literature (Beeson & Kissling, 2001; Bentley, 2006; Daley, Kirkpatrick, Frazier, Misook, & Moser, 2003; Higgins, 2005; McGee, Gramling, & Reid, 2010; Penprase, Harris, & Xianggui, 2013; Phillips, Spurling, & Armstrong, 2002; Yin & Burger, 2003). The rigor of science courses—Anatomy and Physiology I and II, Chemistry, and Microbiology—contributes to the science GPA being the best predictor. The exact courses included in the science GPA may vary, but the predictability does not. In the literature, a science GPA between 2.75 and 3.0 has been suggested as the standard. However, each program needs to determine the benchmark that is best for its student population. The CIP instituted by the BSN program and the diploma nursing program used a science GPA of 2.75 as an admission requirement for nursing students in lieu of an overall GPA of 3.0. Previously, both programs used the overall GPA as an admission requirement. The BSN program found that, prior to the institution of an admission policy calling for a science GPA of 2.75, students were able to take additional, less rigorous courses to raise the overall GPA presented to the admission committee. Preadmission testing was not used in either program as a requirement for admission. Progression Policies

To develop progression policies in an effort to produce successful graduate nurses, educators should begin by examining their curriculum to ensure it includes the necessary knowledge and skills for safe nursing practice. A sample template for curriculum mapping can be found in Table 3. Educators should have learning outcomes, outlines, teaching strategies, and evaluation methods at their disposal as they review each course. Mapping each course as to the concepts taught helps locate curriculum gaps and redundancies. The Detailed Educator NCLEX Test Plan is invaluable for ascertaining the concepts students require because it is based on the practice analysis (NCSBN, 2013, p. 1; NCSBN, 2014, p. 1). After the courses have been revised through curriculum mapping, educators can direct their attention to the evaluation methods used in each course. The BSN and diploma programs increased the use of objective testing to 90% of the evaluation methods for nursing courses. Student course grades caused little attrition in both programs. During an analysis of the BSN program’s evaluation methods, it was found that as little as 40% to 60% of course grades were devoted to objective testing in a number of clinical courses as an evaluation method. Objective testing was devoted to 80% of the method of evaluation in some clinical courses in the diploma program. In the diploma program, test questions focused on the cognitive and comprehension levels of Bloom’s Taxonomy as opposed to those at the application and analysis level. These issues were thought to be contributing factors towards the drop in the first-time pass rate. A policy was devised whereby 90% of the course evaluation would be devoted 40

Journal of Nursing Regulation

TABLE 2

Plan-Do-Study-Act Cycle 1. Plan

Be objective. Make predictions. ⦁ Plan to complete the cycle. ⦁ Plan to collect data. ⦁ ⦁

2. Do

Carry out the plan. Document observations. ⦁ Record data. ⦁ ⦁

3. Study

Analyze data. Compare results to predictions. ⦁ Summarize what was learned. ⦁ ⦁

4. Act

⦁ ⦁

Determine which changes must be made. Begin a new cycle, if necessary.

to multiple-choice testing according to the NCLEX format. Testwriting workshops were held for the faculty at the diploma program to help them in writing test questions at higher cognitive levels. Including objective testing as 90% of the course evaluation methods provides students with ample opportunity to experience NCLEX-type questions as they progress through the nursing curriculum (Rollant, 2007). Examination questions should follow the NCLEX standard. Test items at the cognitive levels of application and higher are employed because the practice of nursing requires complex thought processing (NCSBN, 2013, p. 4). Examination questions are written as multiple-choice items with four responses. Alternate-format questions include hot spot, multiple-response, audio clips, graphic options, charts and exhibits, calculator items, fill-in-the-blank, and ordered response items. Faculty peer review of examinations helps ensure that questions are written at the appropriate difficulty level and according to the test blueprint. Progression policies should include the acceptable passing grade for clinical courses and the number of times a course may be repeated. Cumulative or selected nursing course GPAs have been found to predict a first-time pass rate on the NCLEX (Alameida et al., 2011; Daley et al., 2003; Gilmore, 2008; Sayles, Shelton, & Powell, 2003; Seldomridge & DiBartolo, 2004; Sewell, CulpaBondal, & Colvin, 2008; Trofino, 2013; Ukpabi, 2008; Uyehara, Magnussen, Itano, & Zhang, 2007). This predictor, however, occurs late in a student’s course of study and does little to help the at-risk student. Furthermore, an increased number of Cs in nursing courses correlated with an increased failure rate on the NCLEX (Beeman & Waterhouse, 2001; Bentley, 2006; Norton et al., 2006; Taylor et al., 2014). Repetition of nursing courses was also found to be a predictor of a lack of success on the NCLEX in some studies (Trofino, 2013). Norton et al. described a progression policy whereby students were dismissed from the nursing program after earning a grade of C– or lower in two clinical nursing courses; the NCLEX pass rate increased significantly after the

FIGURE 1

Continuous Plan for Improvement The continuous plan extends from the admission period to program progression to graduation and NCLEX success. Admission Standards

End-of-Program Outcomes

Progression Policies

institution of this policy. The BSN and diploma programs initiating the CIP established a policy whereby the clinical course passing grade was a C and students were permitted to fail either one nursing course or pharmacology twice. More than two clinical or pharmacology failures resulted in dismissal. Tools for Student Success

Remediation for the at-risk student is the cornerstone of student success (Papathanasiou, Kleisiaris, Fradelos, Kakou, & Kourkouta, 2014). Several textbook publishers provide digital learning materials that students find beneficial as they complete course requirements. Online quiz questions, case studies, videos, audios, animations, activities, and games place students at the center of their learning; they personalize learning by determining what, when, and how learning takes place. Furthermore, mobile apps provide students with access to nursing content, practice quizzes, and examinations. Publishers also place test questions for students on Facebook, Twitter, and Tumblr. Such access helps build a community among students and allows students to learn on the go. The impact of such learning methods on programmatic and NCLEX success is not yet known. Nevertheless, studies indicate that social media helps students develop problem-solving skills, enhance networking and collaboration, and engage in course work (George & Dellasega, 2011). Currently, students can also use simulation to enhance learning. Virtual world and serious gaming platforms, such as Second Life™, vSim®, CliniSpace®, Virtual Heroes®, and Shadow Health©, actively engage learners in such activities as patient assessment or intervention in response to changes in a patient’s condition. Research on virtual simulation and student success on the NCLEX could not be located. However, DeBourgh and Prion (2011) found that this instructional method provided students with knowledge and skills and challenged them with experiential learning applied to clinical practice.

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Standardized examinations offer students the opportunity to practice NCLEX-format questions in a computerized environment. Such examinations based on specific clinical course content at the end of each clinical course facilitated student remediation in the BSN and diploma programs. Many packages allow students to review test items they answered incorrectly and view the rationales. Test results can help students learn their strengths and weaknesses. A test after each course provides students with a way to improve knowledge before moving on to the next course. Nursing programs that have adopted remediation policies that include standardized examination mastery with each clinical course found that their NCLEX first-time pass rates dramatically improved. Carr (2011) describes an NCLEX-RN first-time pass rate that increased from a 5-year mean score of 73.2% to 100%. Implementing a progression policy that requires students to pass standardized tests was found to provide student feedback and allow early identification of at-risk students. Most importantly, faculty members were able to design test-taking and remediation strategies well before students took the NCLEX, allowing them to be successful on their first attempt (Bondmass, Moonie, & Kowalski, 2008; Heroff, 2009; Homard, 2013; Norton et al., 2006; Schroeder, 2013). The development of a course to help students at the end of their nursing program has also been found to increase NCLEX first-time pass rates. Some studies have demonstrated that sole use of such a course is associated with an improvement in NCLEX firsttime pass rates (Frith, Sewell, & Clark, 2005; Sifford & McDaniel, 2007), but the BSN and diploma programs demonstrated that such a course should be part of an ongoing remediation plan as part of the CIP. The sole use of end-of-program remediation efforts triggers student stress and lowers self-confidence. When faculty members included remediation throughout the entire course of study, stress decreased and self-confidence increased (Edelman & Ficorelli, 2005; McDowell, 2008). Some nursing programs have tried to focus their remediation on at-risk students. However, identifying students at risk for failing the NCLEX is difficult. Students may have an admission and graduation GPA of greater than 3.0 along with good scores on achievement tests and still fail the NCLEX (Carrick, 2011; Rollant, 2007). Nursing educators are therefore obliged to aim all aspects of an NCLEX success plan towards all students so they benefit from best practices. End-of-Program Outcomes

Toward the end of a nursing program, many schools of nursing have students take a comprehensive exit examination. If given early enough in the last semester, an exit examination can serve as a version of the posttest so educators and students can continue any needed remediation. Conducting this type of testing has been successful in assisting students as well as predicting those who will pass the NCLEX (Carr, 2011; Spurlock & Hanks, 2004). The HESI Exit Exam is a comprehensive examination that emulates www.journalofnursingregulation.com

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TABLE 3

Sample Curriculum Mapping Template Course

Fundamentals

Med-Surg I

Med-Surg II

Med-Surg III

Mental Health

Pediatrics

Women’s Health

Leadership

Concept Oxygenation

X X

Circulation

X

Hygiene

X

Comfort

X

Culture

X

X

Stress

X

X

Communication

X

X

X

Prioritization

X

X

X

Leadership

Journal of Nursing Regulation

X X

X X

X

the test blueprint of the NCLEX and is designed to measure a student’s preparedness for the licensure examination. This exit examination was found to be 96.36% to 98.46% effective in predicting success on the NCLEX in a study of 19,554 subjects (Morrison, 2005). The Assessment Technologies Institute (ATI) RN Comprehensive Predictor examination comparison of 7,126 students showed that when comparing the pass rates of ATI users with those from the NCSBN national database, ATI users passed the NCLEX-RN at a slightly higher rate for the years 2011 and 2012 (Assessment Technologies Institute, 2012). Some programs administer exit examinations as a highstakes test that students must pass before being permitted to graduate. This practice is controversial and has prompted the National League for Nursing (NLN) to publish Fair Testing Guidelines for Nursing Education (National League for Nursing [NLN], 2012). The NLN asks that schools of nursing “implement ethical and evidence-based academic progression and graduation policies.” Placing a student’s degree on hold until a comprehensive examination is passed for the purpose of achieving high first-time NCLEX pass rates is not the intended use of such tests (NLN, 2012). The timing of the NCLEX after graduation is important. Woo, Wendt, and Liu (2009) and Bonis, Taft, and Wendler (2007) found that students who delay taking the examination after program completion are less likely to pass than those who do not delay. Woo et al. (2009, p. 25) reported that the most frequently cited reason for the delay was students’ lack of confidence in their ability to pass the examination. These authors recommend that nursing programs encourage new graduates to take the NCLEX as soon as possible, suggesting that those who are not working in nursing may experience a decline in nursing knowledge over time. A little-used approach to NCLEX success is obtaining stakeholder input regarding the nursing curriculum. Nurse administrators from agencies that employ the school’s graduates are a valuable source of information on the strengths and weak42

X X

X

X

X

X

X X

X X

X

X

X

X

X

X

X

X

X

X

X

X

nesses of the novice nurses they employ. A focus group with chief nursing officers found that areas in the curriculum requiring strengthening included assignment, delegation, communication, teamwork, prioritization, professionalism, collaboration and coordination with an interdisciplinary team, critical thinking and clinical decision making, patient safety, and the use of technology. This information was similar to that found on the HESI Exit and HESI Leadership examinations that helped to inform curriculum revision.

Conclusion The theories of Deming have not only endured over the decades since Deming conceived them but they are as applicable today as in the past (Rungtusanatham, Ogden, & Wu, 2003). Deming provides a framework that lends itself to practical application. The Plan-Do-Study-Act (PDSA) model has been used extensively in manufacturing for quality control since the 1980s (Petersen, 1999). The wide success of Continuous Improvement in industry prompted application of this model in academia (Freed, Klugman, & Fife, 1997). Continuous Improvement demands that educators continually improve their programs by analyzing areas of concern to stakeholders, implementing changes, and repeatedly measuring improvement. Deming believed that too much emphasis was placed on individual mistakes as opposed to creating a systemwide effort. The PDSA model does not subscribe to incremental changes. Instead, this model focuses on complete transformation and nothing less. Many nursing programs seek a short-term solution when they experience a drop in NCLEX pass rates (Carrick, 2011; Pennington & Spurlock, 2010). Without a full study of the data from the program from admission to progression to graduation, total transformation cannot take place. Following an evidencebased comprehensive CIP based on Deming’s model, as described

in this article, can potentially allow NCLEX first-time pass rates to flourish well above the benchmarks set by BONs and accrediting bodies. Moreover, following such a plan helps educators maintain a quality nursing program and graduate new nurses who are prepared for today’s complex health care environment.

References

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Joanne Farley Serembus, EdD, RN, CNE, is an associate clinical professor at Drexel University, Philadelphia, Pennsylvania.