When 9 junior students in our baccalaureate program failed to achieve a score of 85 on 2 attempts at exams developed by Health Education System, Inc (HESI),1 a problem-based learning (PBL) remediation plan was designed and implemented to help these students improve their clinical reasoning abilities. Successfully completing the HESI exam is a progression requirement for advancement to the senior year. PBL teaches students to condense large amounts of information, develop critical thinking skills, and apply the information to a specific situation.2 The remediation plan consisted of an assessment of student learning needs, review sessions, visualization and guided imagery, and a test-taking strategy session. The expectation was that with improved clinical reasoning these students would be more likely to pass the HESI on the third and final attempt and advance to the senior year.

Description of Students

The students consisted of 3 men and 6 women who had no documented learning problems and who spoke English as their first language. The cumulative nursing grade point averages (GPAs) of students who passed the HESI exam on the first or second attempts ranged from 2.91 to 4.00 (X = 3.38). The cumulative nursing GPAs of the 9 students who did not pass the HESI exam on the first or second attempts ranged from 2.24 to 3.37 (X = 3.01).

Assessment of Students

Student assessment included reviewing individual students' previous HESI exam reports to identify areas that needed improvement, talking with students to learn why they thought they failed the exam, and having a counselor meet with students to determine if test anxiety or other stressors interfered with their performance on the exam. In addition, students self-identified their individual learning style by reviewing information presented in the Test Taking Strategies booklet developed by Austin Community College.3

Eight students were "sensing learners" and 1 student was an "intuitive learner." According to Test Taking Strategies,3 sensing learners and intuitive learners differ in the way they process information and in the way they approach test taking. Sensing learners focus on learning facts in a linear manner whereas intuitive learners focus on learning underlying principles or general ideas. Sensing learners scrutinize every word and phrase in a test question and may add inappropriate information to test questions that leads them to choose an incorrect response. Consequently, sensing learners generally use all the time allotted to finish a test.

In contrast, intuitive learners read test questions for a general idea and quickly select the first, often incorrect, response that occurs to them. Thus, intuitive learners finish tests in only a fraction of the time allotted. The intuitive learner was assigned the task of using a watch or clock to ensure that at least 1 minute was spent reading a test question and the choice of answers before selecting an answer. The 8 sensing learners were instructed not to add information to the questions and answers, but to answer the questions based on the situation presented.

Students provided the following reasons for their poor performance on the HESI exam: (a) inability to skip questions and return to these questions during the test, (b) lack of understanding of how to study for the exam, (c) the impression that all questions on the HESI exam had at least 3 correct answers, (d) lack of knowledge of how to take this type of test, (e) lack of trust in their own judgment, (f) stress and anxiety over taking a computerized test, (g) the presence of questions that asked for the initial, first, or most important nursing assessment or nursing intervention, and (h) the fact that the HESI exam covered areas not taught in the curriculum. In addition, students said it would be helpful to have a HESI exam expert available to teach strategies for taking the exam; and suggested that instructors in the nursing program take the HESI exam prior to administering it to students, to determine if any items had been keyed incorrectly.

At the end of the assessment phase each student was given a list of areas that needed improvement. The individual students' lists were used to identify areas that were problematic for the entire group. The group review sessions addressed only those areas that were problems for all the students. Students were instructed to individually review areas not covered during the group remediation sessions.

Review Sessions

Three-hour review sessions were held 1 day per week for 4 weeks with a faculty facilitator. Each session began with a teacher-made test on the topic to be discussed in that session, followed by a lecture/discussion on the topic, a case study, and development of a nursing care plan based on the information in the case study. Topics included growth and development, antepartum, intrapartum, and postpartum care. However, choice of topics should be guided by the areas that were identified to be problem areas for students.

When the initial test was completed, students were asked to give their responses and state why they thought their particular choice of answers was correct. After discussing the item, the correct answer was stated by the faculty facilitator. If a student had failed to answer the item correctly, he or she was asked to reread the question and identify any information that was overlooked or missed when the question was initially read. Students stated that this helped them to understand how they were failing to read test questions thoroughly or making incorrect inferences that were not applicable to the test item.

After the test, a lecture/discussion was held on the day's topic, followed by presentation of the case study on that topic. The case study gave students an opportunity to plan care based on assessment information. Patient problems were identified and prioritized, nursing diagnoses were established, individualized short- and long-term goals were devised, and appropriate nursing interventions were developed. Thus, the review sessions emphasized clinical reasoning and critical thinking skills.

Visualization and Guided Imagery

All review sessions ended with 5 minutes dedicated to visualization and guided imagery designed to help people structure their thoughts by focusing on circumstances that make them feel comfortable.4,5 Students were asked to close their eyes, take slow deep breaths, and to imagine that they were sitting at a computer and taking the HESI exam. They were instructed to visualize themselves as calm, realizing that they knew the information on which they would be tested. Next, students were asked to imagine themselves when they encountered a question that they initially thought was difficult. They were instructed to visualize themselves remaining calm, reading the question and choice of answers carefully, selecting the appropriate response, and proceeding to the next question. Finally, students were asked to visualize themselves completing the exam and seeing a score of 99.99 on the computer screen as their final score.

Test-taking Strategy Session

During the final week, students attended an additional 3.5-hour test-taking strategy session via telecommunication with a faculty facilitator from the main university campus. During this session students were taught test-wise test-taking strategies. When compared to students who are not test-wise, test-wise students approach tests in a more organized, logical, and thoughtful manner and are able to augment content knowledge with test-taking strategies to determine the correct test answers.6 For example, students were taught how to incorporate therapeutic communication techniques with critical thinking skills to improve their ability to recognize the correct response when taking a test. In addition, students were instructed to use stress-relieving measures during test taking and to spend more time answering complex test questions and less time with easier ones. Finally, students were referred to the National Council of State Boards of Nursing,7 and Kaplan International8 Web sites for additional resources on test-taking strategies.

Results

Prior to implementation of the review plan, these students' HESI scores ranged from 60.27 to 83.61. After implementing the remediation plan, all 9 students made 99.99 on the HESI exam and progressed to the senior year. During the last review session, students were asked what needed to be added or changed in the remediation plan for future students. All 9 said nothing needed to be added or changed. Students reported that the test-taking strategy session helped them to develop a comprehensive approach to taking standardized tests and enabled them to use critical thinking and anxiety-reducing skills more effectively.

Attendance at the review sessions was not mandatory. Three students attended all sessions but the remaining 6 students missed at least 1 session during the 4 weeks. When a student was absent, copies of all materials were mailed to the student. Thus, students were not penalized because of work schedules or family emergencies.

Conclusion

These students were able to successfully pass a customized HESI exam. Implementation of a faculty-facilitated remediation plan helped students focus on their individual learning styles, and develop strategies to overcome the inherent difficulties of their particular learning style. In addition, students were able to develop strategies to improve their critical thinking and improve skills in taking computerized tests.

References