Students and faculty alike are concerned about performance on National Council Licensure Examination for Registered Nurses (NCLEX-RN) (National Council of State Boards of Nursing, Chicago, IL) because the consequences of failure are troubling for both. For students, failure to pass the NCLEX-RN results in delayed employment as a registered nurse, loss of income, and harm to self-esteem. For faculty whose careers are focused on teaching, there is a genuine concern for students facing licensure failures. In addition, there is a concern for the integrity of the nursing program-failure of NCLEX-RN by a substantial number of students can jeopardize a program's reputation.

The National Council of State Boards of Nursing1 first made the NCLEX-RN computer-based in 1994, and then raised the passing standard in 1998 and 2004. Between 1999 and 2004, the national pass rate on the NCLEX-RN ranged from 83.82% to 87.0% for all first-time takers.1 This national pass rate counters a program's needs to have a high level of student success on the NCLEX-RN. Thus, the purpose of this article is to disseminate one baccalaureate program's efforts, and resulting best practices, to improve NCLEX-RN pass rates using a systematic analysis and implementation of a course designed to address the identified problems.

LITERATURE REVIEW

In order to understand NCLEX-RN failure and try to prevent future failures, nurse educators have conducted numerous studies looking for antecedents to failure including student demographic characteristics, academic performance before entering nursing, and academic performance in nursing. Only studies published after 1994 are included in the review since this was the date when computer-based testing was initiated. Demographic characteristics that have been investigated include age, gender, and race, and the findings are mixed. Age has been found by some researchers to be associated with NCLEX-RN outcomes where non-traditional-aged students (over 23) have passed the NCLEX-RN at higher rates than students of traditional college age.4-6 However, others have found that age is not a significant predictor for NCLEX-RN success.2,3 Gender has not been shown to affect pass rates.3,4,7

Similarly, Endres8 found that race was unrelated to performance on NCLEX-RN. In contrast, researchers found that African Americans had a significantly higher failure rate than Caucasians,7 and international students from Africa failed at a higher rate than native-born American students.5

Academic performance in prenursing courses and on standardized tests has been investigated to determine if NCLEX-RN failure can be predicted by these scores. Grade point average (GPA) has been identified as a predictor of NCLEX-RN failure wherein students who do not pass NCLEX-RN on the first attempt exhibit lower GPAs as compared to those who do pass NCLEX-RN.2,4,8,9 Moreover, students who passed NCLEX-RN had significantly higher science GPAs, Scholastic Aptitude Test (SAT), or American College Test Assessment (ACT) scores as compared to students who failed NCLEX, who had significantly lower2,4,6,9 In contrast, another study reported no difference in SAT scores of those who passed as compared to those who failed the NCLEX-RN.3 Finally, prenursing standardized examinations, such as Nurse Entrance Test (NET) or Arnett Pre-RN Readiness Examination, have been found to predict NCLEX-RN failures.7,10

Several factors have been associated with NCLEX-RN failure for students enrolled in nursing programs including grades in nursing courses, scores on standardized examinations, and end-of-program exit exams. The number of Cs earned by students in nursing courses was found to be predictive of NCLEX-RN failure wherein more Cs increased the risk.3,4,11 Moreover, failure of a single nursing course was found to be associated with NCLEX-RN failure.2,8,9 Similarly, Daley et al6 found overall GPA in nursing courses to be predictive of NCLEX-RN failure. Student scores on norm-referenced exams such as the National League for Nursing (NLN) Achievement tests were found to be predictive of NCLEX-RN performance.5,11 Finally, end-of-program exit exams were found to be strong predictors of NCLEX-RN performance.4,6-16

Nurse educators have asked students about their preparation for NCLEX-RN to see what factors influence success. Eddy and Epeneter17 interviewed 10 students who passed NCLEX-RN on the first attempt and nine students who did not. They found that students who passed the NCLEX-RN took responsibility for learning, paced their preparation, took the exam when they felt prepared, and used stress management strategies to cope with the inevitable emotional responses to the examination. Students who failed the NCLEX-RN failed to identify a reasonable plan for review, felt confident prior to the test but became quite anxious during the test, perceived pressure by others to take the exam before they were ready, believed that they had not known how to take an NCLEX-RN exam, which requires critical thinking instead of recall of fact-based knowledge, felt they lacked knowledge in some content areas, and felt that they were not able to manage the anxiety that occurred during the exam.

Although the financial consequences of failing the licensing examination are substantial for students, the psychological consequences are more disturbing. Using a qualitative design, 10 nursing graduates who had failed the NCLEX-RN were interviewed to gain an understanding of this experience.18 Several themes emerged including: carrying failure as a daily burden; losing the of identity of being a nurse; doubting past accomplishments; seeing self as damaged goods; wanting support; and daring to hope. The authors described the experience of NCLEX-RN failure resulting in feelings of abandonment. In addition, graduates who failed the NCLEX-RN stated they felt cut off from the community of faculty and students who had been important to their learning experience while in a nursing program.

Anxiety, specifically test anxiety, has been linked to exam performance. Hight19 found that nursing students in a statewide survey of diploma, associate, and baccalaureate programs had higher anxiety scores on the State-Trait Anxiety Inventory for Adults than national norms for college students. Students in the study reported that taking tests was their greatest source of stress. Similarly, stress has been shown to contribute to performance on exams and students taught to use stress management techniques report decreased test anxiety.20

The experience of NCLEX-RN failure is devastating. In order to mitigate failures, nurse educators have given careful consideration to strategies which will prepare students to successfully pass the NCLEX-RN on the first attempt. Mills et al20 offered a preparation course to students who scored below the 20th percentile using an unsecured version of the Mosby AssessTest. The course consisted of nursing content review, completion of 1,200 practice questions, help with test-taking skills, and assistance with study habits. The course also included work on psychological issues that impact students such as restructuring of irrational, negative thoughts about test questions or NCLEX-RN performance, journaling feelings, and developing strategies for dealing with test anxiety. Journals of students revealed that students used at least one strategy taught in the course to reduce anxiety, think positive thoughts, and manage study time. The benefits of relaxation exercises were documented as well. The authors20 reported that students rated stress as 7.03 before performing relaxation exercises, whereas students rated stress as 2.2 afterward. Posttest scores on the Mosby AssessTest were significantly higher than pretest scores for those in the review course. Students' test scores changed from 21 points below the baccalaureate norm group to only 12 points below the norm group. Sixty-three percent of these at-risk students taking the review course passed the NCLEX-RN on the first attempt. This multifaceted course, which included review, practice, and support, could be an important method of preparation for NCLEX-RN.20

PROGRAM DESCRIPTION AND STUDENT EVALUATION

A baccalaureate nursing program located in the Southeastern United States in a liberal arts university has had a continuing interest in establishing best practices in NCLEX-RN readiness preparation. The average age of the students in the nursing program is 25, and 88% are female. The racial composition of nursing students is: White non-Hispanic 87.5%, Black non-Hispanic 9.5%, Hispanic 0.5%, Asian Pacific Islander 1%, and unknown 1.5%. Two cohorts of nursing students are admitted each year, and the total nursing enrollment is approximately 160. The University and the nursing program have required completion of the Mosby AssessTest as a graduation requirement since 1987. Students had a maximum of two attempts to pass the exit exam in the semester. If unable to pass, the students were not allowed to graduate; instead, they took an NCLEX-RN preparation course produced by a nationally known company and were offered another opportunity to pass the exit exam. The pass rates of first-time writers of NCLEX-RN at the University had been consistently 85% to 95% for a decade. However, in 2001, the pass rate fell to 73%. Students and faculty members were distraught at this outcome. However, the poor outcome provided the impetus to conduct a thorough program review and investigate students' preparation for the NCLEX-RN. The first step in the analysis was to look at student characteristics to determine if correlations existed similar to those identified in the literature.

In the graduating class of 2001 (a cohort of 67 students), 51 passed the NCLEX-RN on the first attempt and 16 failed. The mean cumulative GPA for students who passed the NCLEX-RN was 3.14, whereas the mean GPA for those who failed the exam was 3.07, and the differences between the means for the groups were not statistically significant. The cumulative GPA for all students and their scores on the Mosby AssessTest (the exit exam at that time) were weakly correlated (r = 0.30, P < .014). There was no correlation between SAT scores and Mosby AssessTest scores. Five of the 16 students (31%) who failed NCLEX-RN had failed a previous nursing course. Three (18%) male students failed the NCLEX-RN. A final evaluation was made of standardized tests that were administered to this cohort. Five NLN Achievement tests were administered throughout the curriculum, including Basic Nursing Care II, Baccalaureate Mental Health, Nursing of Childbearing, Children across Community, and Baccalaureate Adult Health. Scores on each of these exams were significantly correlated with the Mosby AssessTest scores. The lowest correlation was found between the Mental Health NLN and Mosby AssessTest (r = 0.527, P < .0001), and the highest correlation was found between the Baccalaureate Adult Health and the Mosby AssessTest (r = 0.773, P < .0001).

Based on the findings from this part of the evaluation, several conclusions were drawn. First, the faculty members could use NLN Achievement tests to predict future performance on the Mosby AssessTest. Second, students who had performed poorly on those tests were at risk for failing the Mosby, and subsequently, the NCLEX-RN. Third, based on faculty qualitative feedback, it was believed that the students had an inaccurate perception of their readiness for the NCLEX-RN and needed further faculty guidance. Finally, paper-and-pencil tests failed to provide students with practice for computer-based testing, did not provide rationales for missed items, and required a delay in returning examination results. For those reasons, faculty considered changing from paper-and-pencil tests to computer-based tests and implementing a new NCLEX-RN preparatory course in the curriculum.

CHANGE IN NORM-REFERENCED EXAMINATIONS

The nursing faculty used a data-based approach to determine changes for standardized testing across the curriculum. Faculty reviewed available computer-based tests and selected one that met the need for rapid scoring and immediate feedback through provision of question rationales. The Health Education Systems Incorporated (HESI) Exit Exam (Health Education Systems Incorporated, Houston, TX) was selected because it met these requirements and because its published psychometric characteristics were strong.12-16 The next step in the process was piloting the HESI Exit Exam. The faculty administered two types of exit exams to the 2002 cohort in order to determine if the computerized HESI Exit Exam was equivalent to the paper-and-pencil exit exam, the Mosby AssessTest. Students were given the HESI Exit Exam in January and the Mosby AssessTest in April of their final semester in the program. The Mosby AssessTest was used to determine eligibility for graduation; the HESI Exit Exam was used only for internal evaluation. A high correlation between the Mosby AssessTest scores and the HESI Exit Exam scores was found (r = 0.723 P < .0001). The faculty then studied the relationship of these two exit exams to the NCLEX-RN by matching scores with students' outcomes (pass or fail) on the NCLEX-RN. At the time, the school had established a passing score for the Mosby AssessTest of 60%; 12 of the 60 students in the cohort failed to achieve this score on the exam and were required to take another Mosby AssessTest before graduation. Chi-square analysis (see Table 1) revealed that four students who subsequently passed the second Mosby AssessTest and six students who passed the Mosby AssessTest on the first attempt ultimately failed NCLEX-RN ([chi]² = 3.0, df = 1, P < .05). The faculty was faced with a decision: set a higher passing score on Mosby AssessTest or adopt HESI Exit Exam and require achievement of a specific score that would differentiate between those expected to pass and those expected to fail.

Table 1 Chi-Square Analysis of Mosby AssessTest and NCLEX-RN for the Class of 2002

Before making the decision to adopt a new exam, the mechanism for determining a reasonable passing score was needed to be established for future cohorts. The passing score was established by examining the first exit exam score and the outcome on the first attempt of NCLEX-RN for the 2002 cohort. Verification of passing NCLEX-RN on the first attempt was obtained and then added to a spreadsheet containing the scores on Mosby and HESI exam scores for each graduate. In the 2002 cohort, students with a raw score of 64% or higher on the Mosby AssessTest passed the NCLEX-RN on the first attempt. Students who achieved a HESI score of 84 or higher on the HESI Exit Exam passed the NCLEX-RN on the first attempt. Because the Mosby AssessTest and the HESI Exit Exam were highly correlated and individually predictive of passing the NCLEX-RN, the faculty felt comfortable with making a change and adopted the HESI Exit Exam as a graduation requirement for this nursing program. The passing score was set at 85 (later 850 when HESI changed its scoring scale) based on this internal analysis and on the published results of the fourth HESI validity study.16 Faculty also voted to change all standardized exams for individual courses from NLN Achievement Tests to HESI Specialty Exams.

IMPLEMENTATION OF REVIEW COURSE

Following a review of student scores on the standardized testing adopted throughout the curriculum, and because faculty expressed concern about student preparation for the HESI Exit Exam and NCLEX-RN, a new course was added to the curriculum in spring 2003 entitled Integrated Clinical Concepts. This one-credit-hour course was designed to support, motivate, and test students, so that each student who graduated from the University's nursing program would have an excellent likelihood of passing the NCLEX-RN on the first attempt. The course was offered in 2-hour intervals for the first 8 weeks of the semester and included an attendance policy. Similar to the course described earlier,20 Integrated Clinical Concepts combined support for psychological issues (test anxiety and negative self-talk) with cognitive preparation (content review, test-taking strategies, and practice questions).

The Integrated Clinical Concepts course included unique features identified from the faculty's investigative process. First, the course faculty member described the history of requiring exit exams for completion of the nursing program and provided statistical evidence linking strong exit exam performance with NCLEX-RN success. Emphasis was placed on the fact that good preparation for the HESI Exit Exam was also excellent preparation for the NCLEX-RN. Second, in a password-protected course Web site, students were confidentially provided with their scores on HESI Specialty Exams and a predicted score on the HESI Exit Exam. The prediction equation was based on the scores of the 2002 graduating cohort. The faculty member asked to meet with each student predicted to score less than 850 on the HESI Exit Exam to develop a study plan (50% of students were predicted not to pass on the first exit exam in spring 2003). Third, if students had a score below 850 on a previous HESI Specialty Exam, they were required to retake the exam during the course. All HESI Specialty Exams were scheduled at intervals so that study in the corresponding content area could be completed prior to testing. Students were encouraged to purchase the HESI study materials (an NCLEX-RN review book and CD-ROM containing practice questions). Finally, the course incorporated case studies that assisted students in applying their knowledge to new situations.

THE RESULTS

The academic and nonacademic support provided in Integrated Clinical Concepts has led to positive changes in HESI Exit Exam scores and NCLEX-RN pass rates. Figure 1 shows the pass rates for first-time HESI exams. The trend is extraordinary, ranging from a low 30% pass rate for first-time takers of HESI Exit Exam for the 2002 cohort to an 89% pass rate for first-time takers of HESI Exit Exam for the 2005 cohort. Likewise, NCLEX-RN first-time pass rates show vast improvements, beginning with the spring 2002 cohort demonstrating 83% success for first-time takers and all other cohorts exceeding a 90% pass rate (see Figure 2). Table 2 shows students' scores on the HESI Exit Exam based upon their NCLEX-RN outcomes for students in cohorts who took Integrated Clinical Concepts and for whom NCLEX-RN results are known. The first-time HESI Exit Exam mean composite score for all students who failed the NCLEX-RN was only 790, which is below the school's minimally acceptable passing score for exit exam of 850. The mean score of students who passed the NCLEX-RN was 928. For these students, a statistically significant difference was found on the HESI Exit Exam score on the first attempt between those who ultimately passed or failed (t = -3.772, df = 140, P < .0001). Students who failed to meet the school's required minimally acceptable score of 850 were required to take a second version of the HESI Exit Exam, but the score earned on the first version of the HESI Exit Exam that the student attempted was used to identify students at-risk for achievement of NCLEX-RN success.

Table 2 Mean Scores on HESI Exit Exam Version 1 for Students Who Passed and Failed NCLEX on First Attempt 2003-2004

FIGURE 1. Comparison of pass rates for HESI Exit Exam V1 fall and spring semester cohorts 2002-2005 (

FIGURE 2. Comparison of pass rates for NCLEX-RN for all cohorts their level of serious preparation for the NCLEX-RN 2001-2004 (

Although the nursing program had required an exit exam for nearly 20 years, the implementation of Integrated Clinical Concepts was not easy. Faculty members spoke frankly to students about previous cohorts' poor performance on HESI Specialty Exams so that students could be encouraged to plan study time and avoid procrastination. However, in the first course offerings, students were learning the new expectations for the HESI Exit Exam and realized the challenges they would face as they progressed through their last semester of the program. The students' challenges and resulting emotional needs were overwhelming at times for the course faculty. As the nursing faculty reinforced the importance of achieving an acceptable score on the HESI Specialty Exams presented throughout the curriculum, students began taking them more seriously and they began coming to their last semester better prepared for the HESI Exit Exam. Course faculty also became better prepared for the emotional reactions by students who failed on their attempt at the HESI Exit Exam and they were better able to assist these students in preparing to take a second version of the Exit Exam. Support by the entire faculty for those members teaching this course was critical to both student and faculty success.

Student evaluation of the Integrated Clinical Concepts course was favorable overall. The course evaluation was completed by 41 of 50 (82%) students in spring 2004 (see Table 3). Most students agreed that the objectives of the course had been achieved. The course objective "Complete the HESI Exit Exam as a mock NCLEX-RN exam to predict pass rate on the licensure exam" was perceived as not met by 5% of the respondents. This might be related to evaluation comments that the exit exam tested "obscure, least discussed information." Some students said that they guessed a good bit on the HESI Exit Exam, and this comment likely reflects their lack of confidence about their level of serious preparation for the NCLEX-RN at that point within the nursing program.

Table 3 Student Evaluation of Course Objectives

Most students found the teaching strategies to be helpful. One student said, "This course was very helpful to me. The HESI book (HESI NCLEX-RN Review Manual) was great. If we hadn't had all the information in bullet form in one book, I am afraid that I wouldn't have known where to start studying my notes. I would have been very overwhelmed and probably wouldn't have done well. I have more confidence going into the NCLEX-RN now after this class." Another student echoed these thoughts, stating, "I feel that I was helped most by taking the specialty exams and reviewing the HESI manual." Several students stated that the HESI StudyWare CD-ROM containing the study questions made them worry more because they performed poorly on those tests. Students informally stated that having the Specialty Exams scheduled throughout the semester made them study regularly. One student reported, "The practice tests showed me the areas where I was the weakest." Many students suggested that graduating students receive a review of content by faculty before the exit exam as a way of clarifying and asking questions on the subject matter. There were mixed responses to viewing the HESI prediction score: some students found that viewing their score served as a stimulus to study, while others found it to be discouraging. One student wrote, "Thanks for all the support and for being blunt about the fact that I needed to study to do well. Your words put me into study gear."

Students were asked to provide suggestions to future students taking the review course in preparation for the exit exam and NCLEX-RN. Their advice for other nursing students reflected a sense of self-responsibility for their success, the ability to be persistent in their efforts, using their resources wisely, and taking care of themselves. The suggestions also mirrored findings reported in the literature.17,18 Suggestions included:

* Self-responsibility: Take control yourself, create a study schedule, and stick to it.Take all of the case studies and specialty exams seriously.Use the HESI StudyWare CD-ROM to identify your weakest points before taking any tests.

* Persistence breeds knowledge and confidence: Take practice exam questions in review books and take practice tests while you time yourself. Take all of the specialty exams to improve your confidence. When you take exams throughout the semester, you study consistently. Study the entire semester; do not wait until the last minute.

* Know your resources: Use course professors and techniques to reduce anxiety if you get nervous. Use the online case studies to prepare for the HESI. Use the HESI StudyWare CD-ROM to identify the kinds of questions that will be asked of you on the Specialty Pharmacology exam. Make flashcards for the unfamiliar meds.

* Self-care: Take a day or two off before the exit exam and relax. In between study periods do something to get your mind clear so that you can come back and absorb the information and use your time efficiently.

BEST PRACTICES FOR PREPARING GRADUATES TO PASS THE NCLEX-RN

Since the first presentation of the course, faculty have made further modifications and improvements.Faculty members have been added to the course to facilitate mentoring, meeting the goal of maintaining an approximate 1:8 teacher-to-student ratio.The faculty mentors meet with students either collectively or individually on a weekly basis.Students who did not pass the first exit exam are expected to continue to work with their faculty mentor for an additional 4 weeks before taking a second version.

Based on the academic achievement of the cohorts, student evaluations and faculty observations, and evidence from the nursing literature, the following best practices have been implemented for the Integrated Clinical Concepts course:

1. The HESI NCLEX-RN Review Manual and HESI Case Studies are required.Specific dates for the completion of Case Studies are placed on the course calendar.

2. Class time is used to "think out loud" about questions on the HESI StudyWare CD-ROM in small groups or for students to work on HESI Case Studies individually.

3. HESI Specialty exams are scheduled for all students who have scored below a minimally acceptable HESI score of 850 in previous courses at specific times within the course, allowing for adequate preparation time.

4. Content review is conducted by faculty in the specialty areas 1 week prior to the exit exam.The review is required for students who have scores below 850 on the HESI Specialty Exams and it is an optional activity for others.

5. Predicted HESI Exit Exam scores are provided at the beginning of the semester in a password protected area.Those predicted to score below 850 are advised by the faculty mentor about developing a calendar with study activities specified.For example, students are required to specify dates for completion of all of the HESI Case Studies.

6. Students who score high (over 20)on Sarason's21 Test Anxiety Scale are referred to the University's counseling services.

7. Students who achieve HESI specialty exam scores over 950 are asked to become official University tutors for students with predicted HESI Exit Exam scores below 850.Students who are tutors reinforce learning for others, as well as themselves, as they teach.

8. The course coordinator is carefully selected as one who can motivate students, conduct statistical analyses of HESI exam scores accrued throughout the curriculum, and be supportive of struggling and unsuccessful students.

9. A faculty/student ratio of 1:8 is used so that mentoring of students with a history of scoring below 850 on HESI Specialty Exams is possible prior to the exit exam.Responsibility for mentoring these students is distributed evenly among the course faculty.

10. The entire nursing faculty is dedicated to improving HESI Specialty Exam scores so that students can have the opportunity to improve earlier in the curriculum rather than waiting to bolster weaknesses within the last semester.This approach can lessen the anxiety for students and reduce the related stress on the faculty.

The evidence-based approach based on findings from the current nursing education literature that was used by the nursing faculty to select evaluation tools for use throughout the curriculum and the addition of a review course resulted in improved HESI Exit Exam scores and NCLEX-RN success. The nursing faculty members are committed to continuous improvement necessary to achieve program outcomes, and they will continue to monitor the impact of the Integrated Clinical Concepts on NCLEX-RN success by monitoring test results of students enrolled in this course. Students have begun to understand that waiting until the last semester to prepare for the licensure exam is unwise; many seniors recommend the HESI NCLEX-RN Review Manual to juniors and encourage them to take HESI Specialty Exams seriously. The experience, while difficult at times, has resulted in positive outcomes for all.

REFERENCES