Preparing RN graduates to not only succeed on the National Council Licensure Exam (NCLEX(R)-RN) but to do so on the first attempt has long been the gold standard for nurse faculty (Giddens, 2009). However, with a call to increase the diversity of RN graduates and changes to the National Council of State Boards of Nursing (NCSBN) passing score in 2013, achievement of this benchmark has become increasingly challenging for graduates and faculty (Noone, 2017; Pullen, 2017). With the continuing demand for new nurses in the workforce, there is a call for accreditation bodies to reevaluate the gold standard. What is the best practice for evaluating the quality of nursing schools (Noone, 2017; O'Lynn, 2017; Walters & Davis, 2014)?
BACKGROUND
As early as 2005, Bernier and colleagues encouraged the nursing community to examine if, in fact, the first-time pass rate of graduates was truly a reflection of a strong nursing program (Bernier et al., 2005). In 2014, following the scoring revision by the NCSBN, Taylor et al. revisited the question and argued that graduates bring to the NCLEX testing period a diverse set of influential variables for potential success (e.g., strength in testing skills, management of test anxiety, being sick on examination day). They strongly encouraged the nursing community to consider these variables when determining the gold standard for NCLEX pass rates. Both Noone (2017) and O'Lynn (2017) continued to provide evidence that first-time pass rates do not provide the best evaluation for nursing program quality, suggesting that this standard might impose a bias that would hinder the admission of first-generation and diverse students to nursing programs. Noone (2017) and O'Lynn (2017) encouraged American accreditors and licensing boards to expand the gold standard to be based on NCLEX passage during the first year, rather than the first examination following their graduation.
Despite these considerations, it must be recognized that first-time passage is preferable for two reasons. First, statistics reflect that graduates who fail NCLEX on their first attempt have a greater than 50 percent chance of failing the examination on retakes (NCSBN, 2017). Second, schools of nursing recognize that not passing the first time leads to emotional, financial, and personal life stressors for new graduates.
MODEL FOR NCLEX SUCCESS
Until the gold standard for first-time pass rates is modified, nurse faculty must aggressively address preparation strategies to achieve first-time success. Our strategy has been implemented successfully for five years during the last semester of a baccalaureate nursing curriculum with approximately 200 to 230 graduates per year. It involves facilitating students in implementing the nursing process to develop a holistic (body, mind, spirit, environment) personal learning plan. Personal reflection is taught and implemented throughout the curriculum, beginning in the freshman nursing course. Specifically, students are directed to examine how they best learn, their overall course grades/program performance, achievement on eight NCLEX nursing categories, areas to strengthen after practicing computer-adaptive comprehensive (CAC) NCLEX-style exams, and external variables that might potentially impact their success. Based on 13 years of implementing the NCLEX preparatory class, one-on-one counseling of the 15 to 20 annually who did not pass NCLEX on their first attempt, and evaluating variables that impact success, the following model is proposed as a means of understanding the three most significant variables for success.
The primary variables impacting NCLEX success are nursing knowledge, followed by testing skills and external variables. As noted by Alameida et al. (2011), nursing knowledge has long been identified as a must to succeed on NCLEX, with increasing awareness that the attainment of strong testing skills is needed to ensure success. The label "external variables" was described by Taylor et al. (2014) as life-impacting situations, test anxiety, and unexpected "environmental factors in the testing center" (p. 340).
Nursing knowledge is paramount and, in theory, should be attained by students who successfully completed the nursing program. Strong testing skills involve being able to carefully dissect test questions, clearly interpret what is being asked, evaluate all answers, and select the "best/safest" response. The concept of external variables surfaced as this author explored with graduates what factors might have impacted their first NCLEX attempt. Graduates identified the following external variables: extreme test anxiety, relocation either in housing or move to another city/state, and personal life events (e.g., marriage; end of long-term relationship; death of family member/significant other; illness of graduate, family member, or significant other; or celebration of a religious/cultural period).
Through an understanding of the influence of these variables, our students have engaged in developing nursing process-driven holistic plans of care to enhance and maintain their nursing knowledge, critical thinking, prioritization, and provision of safe, quality client care. The plan is student driven and encompasses the last semester of nursing school through the anticipated date of NCLEX. Implementation involves promotion of self-care, engagement in extensive focused CAC testing, identification of external variables, and participation in two simulated proctored NCLEX-style examinations with 265 questions.
This extensive preparatory process is analog to training for a marathon. The process involves establishment of an individual holistic, personal self-care and learning plan, weekly computerized testing with continued scaffolding of nursing knowledge and critical thinking through review of all questions with rationales, engagement in two simulated, proctored NCLEX testing experiences, and the ongoing evaluation and management of identified external variables. Following graduation, graduates are provided 60-day computerized high-level testing utilizing NCLEX-style questions. They are encouraged to achieve 65 percent to 70 percent scores (95 percent confidence interval) prior to taking the NCLEX. This plan has moved this university's NCLEX pass rate from 82 percent in 2013 to 93 percent in 2018 (Oregon Board of Nursing, 2019).
TESTING PRACTICE
To address the variable of testing, faculty engage students in strenuous computer-adapted testing that involves multiple practice comprehensive tests and focused quizzes in eight client needs categories. Students are encouraged to implement, review, and identify nursing concepts that need strengthening. Faculty provide students with a step-by-step guide to approach test questions.
Two simulated NCLEX testing opportunities help students develop personal preparation skills to ensure success (e.g., resting the day before, sleeping well before testing, managing stress level before and during the examination, eating a high-protein meal prior to testing, bringing snacks/water to the testing center). The testing environment is designed to mimic that of the NCLEX testing centers with personal items stored at the front of the room and not accessible during testing. Snacks and water are placed on a table near the exit; students may take breaks as desired by exiting the room with a hall proctor and are instructed not to talk. Students are given six hours to complete the CAC examination; a 265-item examination was selected to help student gain confidence, a testing strategy documented by Czehanski et al. (2018).
Once students succeed on the simulated NCLEX, faculty continue to encourage them to explore any possible "external factors" that might impact their locus of control on the actual testing day. University resources, including mental health counseling and spiritual support, are identified. Students develop an organized plan starting from the date of graduation until NCLEX testing to foster maintenance of nursing knowledge, testing skills, and management of external factors. Faculty help students explore the advantages, costs, and learning strategies of additional NCLEX preparation resources; the previous year's graduates take part in a panel presentation, sharing their "lived experience of NCLEX"; and students are given an in-depth checklist to eliminate or minimize stress prior to the NCLEX date.
Graduates are given a package of standardized CAC examinations and encouraged to maintain their strong testing skills by taking two to three examinations each week, with at least one examination consisting of 265 questions. To ensure a 95 percent confidence interval, students are encouraged to consistently achieve a score of 65 percent to 70 percent. They are instructed to set aside time within 24 hours from each practice exam to thoroughly review the rationale for each test question. Faculty have access to graduates' performance and provide feedback if requested.
CONCLUSION
Although the gold standard first-time pass rate on NCLEX is being evaluated, nurse faculty need a comprehensive plan to prepare graduates in attaining licensure. Committed to supporting increased diversity in the nursing workforce to enhance health care outcomes, we must address methods to ensure graduate success. This commitment requires providing effective resources to enhance graduates' success on NCLEX and transition into their nursing career. The proposed method of preparing graduates to succeed on NCLEX would empower nursing faculty by providing strategies to meet the learning needs of diverse students and provide populations with a nursing force that reflects the diversity of the world.
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