Nursing programs across the United States strive for student success on the NCLEX-RN. Failure can be devastating for new graduates, and low pass rates can have a detrimental effect on program accreditation, funding, and reputation. Desire to maintain high first-time NCLEX-RN pass rates has prompted nursing programs to invest time and energy into remediation when students perform poorly on standardized comprehensive exit examinations. Nursing programs use various strategies to provide enrichment and preparation for the NCLEX examination. Standardized exit examinations are widely used in nursing education as a method to predict success on the NCLEX-RN.1 It has been reported that approximately 20% of nursing programs require students to achieve success on the exit examination to graduate.2 Collaborative learning activities associated with test taking could improve students' scores on standardized exit examinations, thus promoting success on the NCLEX.
A large body of evidence in education supports collaborative learning across disciplines.3 Collaborative testing (CT) is not a new concept to nursing education but has reportedly been used infrequently.4 By definition, CT is an interactive learning strategy in which students work together to answer questions on a test.5 Nursing practice requires collaboration, and students need opportunities to develop and practice skills that will prepare them to assume their role as members of the health care team. This study evaluates the effectiveness of CT, its use as a preparatory strategy for improving performance on standardized exit examination scores, and student satisfaction with the CT process.
Background
Research in nursing education has shown that CT is an active learning strategy that enhances communication, critical-thinking, and clinical reasoning skills, as well as group interaction, positive interdependence, and interpersonal skills.6 Several learning theories including cognitive-developmental, behavioral learning, social interdependence, and constructivism (cooperative learning) underpin CT.6,7 Knowledge increases as students work together using active problem solving while defending their position as they answer test questions in groups of 3 to 5 students.7
Nursing programs have used CT in various ways. A strategy known as double testing allows students to take examinations individually, then as a member of a small group.7,8 This approach also has been used as posttest review.9 Mennenga and Smyer10 incorporated CT into a team-based learning approach. Students took a readiness assurance test to assess their preparation level for class, then repeated the same test in groups as a group activity.
The most significant benefit of CT is the opportunity for students to actively practice communication skills by expressing rationale and negotiating, especially when required to arrive at consensus.11,12 Research has shown that CT enhances the student's ability to master skills necessary for collaboration, communication with others, critical thinking, and clinical reasoning.3,7 Double testing promotes group interaction and processing skills, positive interdependence, and interpersonal skills.3,8
Research on CT in nursing education has focused on student and faculty perception of CT and the impact of CT on grades.11 Students have consistently evaluated their overall CT testing experiences as positive.6-8,13 They also have reported that CT helped them understand the course material better while allowing them to practice communication skills they will need in nursing practice.14 Faculty response has been positive, noting fewer negative and argumentative behaviors from students following double testing or test review using CT.7,12,15
In this study, CT was implemented as part of NCLEX-RN enrichment to determine the effectiveness of the strategy in improving standardized exit examination scores. Students were in their final semester of a BSN program at a public university in southeastern United States. The questions that guided the study were as follows: (1) Is there a difference between students' individual test scores and the scores they obtain while participating in small group CT? (2) Does CT contribute to better performance on the comprehensive standardized exit examination? (3) Are students satisfied with the CT process?
Methods
A convenience sample of 43 students participated in 2 test sessions to address research questions 1 and 2. An exploratory descriptive design was used to address research question 3 for the same sample. All students enrolled in their final semester of the BSN program elected to participate. Students worked in assigned cooperative learning groups16,17 with mixed achievement levels based on GPA. The CT activity was conducted as part of the Senior Seminar portion of a clinical laboratory course.
The test for session 1 consisted of 40 questions taken from a standardized online test bank from the client needs categories. Half (n = 21) of the students were tested individually in a computer test laboratory, whereas the other half (n = 22) completed the test using the CT method, allowing them to discuss answers in small groups of 3 to 4 in separate classrooms. Students took the same test (no. 1) either individually or in a small group.
The second testing session occurred 1 week later. A second test of 40 new questions taken from the client needs categories was administered in this session. To give all students the opportunity to experience the CT process, those who had tested individually in session 1 were placed into assigned cooperative learning groups. The students who participated in the CT process in session 1 took the second test individually. Students took the same test (no. 2) either individually or in a small group.
Access to the standardized online test bank was purchased for each student through a grant from the university. Students did not access the tool until the first test was administered. The tests were administered using the online testing tool, which provided immediate scoring and recorded student scores. Students who took the tests individually were allotted 90 minutes to complete it, and the collaborative groups were given a maximum of 3 hours. During the CT testing sessions, students were encouraged to make notes of their rationale as the questions were discussed by the group. Each group member entered his/her own answer, and the group was not required to reach consensus. Students were allowed to review correct answers and discuss their answers at the end of each test session. Proctors were assigned to each group.
Students also completed a self-report survey with Likert-type scale and open-ended questions to evaluate perceived benefit of CT as preparation for licensure examination and in relation to development of oral communication, analysis, critical-thinking, and teamwork skills. The Likert scale included 15 items scored from 1 (strongly disagree) to 5 (strongly agree). Neutral answers were excluded in the analysis.
An independent-sample t test was conducted to determine effectiveness of CT on knowledge gained. Mean scores were calculated for student individual tests and for tests in which students discussed answers collaboratively. To assess the impact that the CT sessions had on the standardized exit examination, analysis of variance (ANOVA) was applied to compare exit examination scores of the previous 6 semesters (2011-2013) to exit examination scores of the spring 2014 cohort that used CT as an enrichment strategy. The average number of students who did not reach the exit examination benchmark from the previous 6 semesters was compared with the study group. The study was approved by the institutional review board of the authors' university.
Results
The independent-sample t test showed that scores from the tests taken collaboratively (mean, 25.74 [SD, = 2.98]) were significantly higher than the scores from the individual tests (mean, 22.55 [SD, 3.80]), t84= 4.32, P < .01. A 1-way between-groups ANOVA indicated no significant difference among the groups (F6,293 = 1.56, P < .158). There was no significant difference between the standardized exit examination scores after the use of the CT intervention and the scores of students in the previous 6 semesters. The data were tested for normality and homoscedasticity using the Levene test before the ANOVA was applied.
The average percentage of students who did not reach the benchmark for the previous 6 semesters was 28.9% compared with 16.3% for the group who had the CT intervention. The CT group also had the fewest number of students required to retake the standardized exit examination because they did not reach the benchmark than any other group in the previous 6 semesters with the exception of spring 2012 (15.8%).
High NCLEX-RN pass rates support quality preparation and enrichment for these students. NCLEX-RN pass rates for the years 2011 to 2013 ranged from 95% to 100% (mean, 97.3%). The NCLEX-RN pass rate for the spring 2014 student cohort in this study was 97.7%.
Student Satisfaction With CT Process
Based on the survey, 97.2% of the students strongly agreed or agreed that they were satisfied with the CT process. Only 2.7% of students were not satisfied with CT. In addition, all students strongly agreed or agreed that the activity contributed in a positive way to their learning, and 93.1% reported that it was beneficial as part of their preparation for the standardized exit examination.
Additional Findings From Students' Responses on Surveys
Items on the survey asked students about their perceptions of the CT activity related to communication, critical thinking, civility/bullying, and group/team building. Students strongly agreed/agreed that the CT activity helped to develop oral communication skills (93.5%), and nonverbal communication was appropriate and respectful in their group (97.3%). All students strongly agreed/agreed that they were able to speak freely and express their ideas and opinions within the group and that other members of their group were able to speak freely too.
Students also indicated that the CT activity helped them to improve their analytical skills (92.3%) and critically evaluate answer options considering group ideas and opinions (97.4%). In addition, they strongly agreed/agreed that the skills practiced in this activity helped to promote their critical-thinking and clinical reasoning ability (94.4%), and CT contributed to the team process and working in a team.
Civility actions and bullying behavior during the CT activity were addressed in survey items. Students indicated that group members demonstrated mutual respect and built trust during this activity (97.4%), although a few students (8.6%) felt pressured or bullied by group members to agree with their answers.
Students' Preference for NCLEX-RN Enrichment
In an effort to determine students' preference in how to enrich for the NCLEX-RN, the survey included a question regarding preference as well as opportunities for the student to comment. The majority of students (56.8%) reported that their preference for NCLEX-RN enrichment would involve both individual and CT. A common theme in comments from this group related to the value of hearing others' opinions and rationales. One student commented, "I think it is good to be able to see how others work through questions, and it can help us to learn new ways to think through them. Also, individual testing is always good." A small percentage of students (10.8%) indicated that CT alone was the best approach for NCLEX-RN enrichment. One student shared, "I was able to learn about peer thought processes and develop my critical-thinking skills further." Some students (29.7%) preferred individual testing as enrichment as exemplified by comments, such as "I can concentrate better by myself" and "I have always been the type that teaches myself and learns better on my own. I get distracted easily in groups."
Discussion
A goal of this study was to identify CT as a strategy that would assist students to answer examination questions in preparation and enrichment for the standardized exit examination and ultimately for the NCLEX-RN. The group test scores using CT were higher than the individual test scores, which is consistent with previous studies evaluating CT.6,11,13,14 This project adds to the body of nursing knowledge by demonstrating the value of CT as a preparatory strategy for high-stakes testing. The cohort mean test score for spring 2014 was higher than all exit examination mean test scores since 2011 with the exception of spring 2012. The standardized exit examination group mean scores from 2011 to 2014 were all above the benchmark, providing 1 plausible reason that examination scores were not statistically significant for the spring 2014 semester when CT had been implemented. However, scores in the categories of effective communication, communication and global health, health promotion/maintenance, and basic care/comfort were higher in spring 2014 than in the previous 6 semesters. It was interesting to note the decrease in the number of students in the CT group having to retake the exit examination because they did not meet the benchmark.
The majority of the students reported satisfaction with the CT process, that the activity contributed in a positive way to their learning, and that it was beneficial to prepare them for the standardized exit examination. This is consistent with other reports of overall satisfaction with CT.6-8,13 In addition, students reported positive perceptions of communication, critical thinking, civility, and team building associated with the CT activity, which is consistent with findings of previous studies.7,12-14 While some students reported their enrichment choice of individual or CT, a majority of the students reported that both of these types of testing would be their preference for NCLEX enrichment.
Limitations
This study had several limitations including small to moderate sample size, limitation to 1 school of nursing, and singular implementation of the CT activity. This study was conducted in 1 semester with 43 senior nursing students. The single school of nursing already had high NCLEX-RN pass rates. Therefore, the study should be replicated in other nursing programs. In addition, CT could be implemented several times throughout a semester or time period and could be implemented in various courses.
In addition, the survey was a self-report of how individual students perceived each item. While that is a subjective report, the mean cohort exit examination scores and particular indicator analysis items support the findings in a more objective way. Future studies could include a more objective method to measure communication and critical thinking; self-report, though, may remain best for items specific to civility and team building.
A few students made comments about choice of team members: "Not allowing us to choose our groups hindered the process," and "If I could choose the peers I test with, I might trust them more." Students did not understand the importance of working in diverse teams and the significance of placement with differing achievement levels. Cooperative learning group principles used in this study helped set the stage for an effective learning environment.
Conclusions
CT is a valuable strategy for NCLEX enrichment. In this study, collaborative test scores were consistently higher than the individual test scores. While this activity was not found to have a significant effect on standardized exit examination scores, some categories' subscores of client needs increased, and fewer students had to retake the standardized exit examination. In addition, NCLEX-RN pass rates remained high.
The benefits of CT surpass the ability to answer questions correctly-even though vital to licensure. Multiple benefits of collaboration include team building, critical-thinking, and communication skills. These are the skills that students perceived as positive following the CT experience. The ability to function as a collaborative member of the interdisciplinary health care team is essential in nursing practice. Students should be given the opportunity to practice critical-thinking and communication skills that enhance their ability to negotiate and provide rationale for decision making as supported in the literature. CT as part of NCLEX enrichment exposes students not only to the process of group decision making, but also to the value of collaboration. The use of CT as an active learning strategy provides multiple opportunities that allow students to develop skills that will benefit them as they enter professional nursing practice.
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