Student success in a nursing program is a source of pride for all stakeholders including patients and families, employers, and the nursing program faculty. The measure of student success addressed in most literature is the National Council Licensure Examination (NCLEX) passing rates. Unfortunately, it is possible to take the success for granted until the bubble breaks and student NCLEX passing rates drop. A spike in NCLEX failures forces the faculty to evaluate a multitude of variables including the quality of admission applicants, grades in nursing courses, remediation and progression policies, use of standardized examinations at the course level and/or midprogram level, and an NCLEX simulation exit examination.
Program Overview
Our undergraduate nursing program is part of a small public liberal arts university located in the southeastern United States. Each academic year, the school admits 2 cohorts of students totaling approximately 80 students. The average age of the students is 24 years, and 94% are women. Self-reported race composition is 1% Asian, 2% Hispanic, 5% African American, and 92% white. There is a block curriculum designed with courses according to specialty, for example, pediatrics, medical-surgical nursing, psychiatric, mental health nursing, and obstetrics.
The faculty began studying NCLEX student success in 2002 when, to their great dismay, an unexpected dip in the NCLEX passing rate occurred. The faculty were uncertain how to address the issue and make improvements. After the shock began to subside, the faculty started scrutinizing the literature. They evaluated studies by Nibert et al1,2 and Newman3 and found predicting NCLEX success to be possible. The faculty also started collecting and trending data at the program level and for individual courses. These activities became a catalyst in developing several evidence-based strategies. These strategies were developed in 3 committees: educational effectiveness, curriculum, and admission and progression. Implementation began after approval by the faculty at large.
Evidence-Based Strategies
Implementing an NCLEX Preparation Course
A new 1-semester-hour course, integrated clinical concepts, was implemented in spring of 2003 for seniors graduating that same semester and included the use of the Health Education Systems Inc (HESI) as an exit examination. Background information for the course development process was described by Frith et al.4 The course has been continually modified using student feedback and exit NCLEX examination passing scores. Currently, students are mentored by the faculty with no more than an 8:1 student-to-faculty ratio. Nursing administrators have made the conscious choice of rotating and involving all course leaders to serve as student mentors. The NCLEX passing rate continues to be carefully monitored by members of the educational effectiveness and the curriculum committees.
Adopting a Progression Policy
A number of studies describe the use of progression policies to improve program outcomes.5,6 After a careful review of the literature and much deliberation, the faculty voted to adopt a progression policy that required students to pass the NCLEX simulation exit examination to graduate from the university. The faculty adopted a progression policy which included an exit examination cutoff score. Students who did not meet the passing score were delayed from graduating until they passed the exit examination. Initially, there was no limit placed on the number of times that the student could take the integrated clinical concepts course. The policy was amended several times over the last 5 years, using analysis of data obtained each semester. The potential negative consequence to students who were considered at risk for failure was a major issue in arriving at the current progression policy. It was a long and an agonizing process.
The required passing score for the exit examination was identified using statistical analysis of NCLEX and HESI exit scores. Initially, the required passing score on all specialty and exit examinations was 85 (changed by HESI to a 3-digit number in 2003 and is currently equivalent to 850). The nursing faculty voted to raise the passing score to 900 during spring semester of 2006. The new passing score goes into effect spring of 2008. There were several reasons for the score increase. First, the grade of 75 is the lowest passing grade on the grading scale used for nursing courses. The HESI scoring of 900 approximated the conversion score of 75. Second, the students were ready. The faculty have worked diligently to improve the quality of the courses delivered, and as a result, 85% of the students were passing the exit examination with a grade of 900 or better by spring of 2007: a 500% improvement from spring of 2002! The faculty believe that the new passing score will best prepare students for the increased passing score on the NCLEX which went into effect in April 2007 (Figure 1).7
Modifying the Exit Examination Preparation Course to Assure Student Success
Currently, students enrolled in the integrated clinical concepts course have 2 opportunities to pass the examination: one at midterm and the other during the week of final examinations. During the first week of class, students take learning style and test anxiety inventories. Students are guided to maximize the use of their learning styles. Students with high test anxiety scores are referred to the university counseling center. The course content is structured to allow students time to review each study discipline and retake a version of the associated specialty examination to assess learning outcomes. Students are instructed to study using a review manual and case studies and practice learning with at least 120 to 150 questions every week. Class time is used for clarification of "muddiest points" and for "think-aloud" sessions. The think-aloud strategy encourages students working in small groups with a teacher to describe why they would choose or eliminate answers for NCLEX-type questions. The muddiest point is used in written homework where students describe concepts that they do not clearly understand after reviewing learning resources.
Specialty examination retakes are required for students who did not previously achieve the benchmark score (the same as the exit examination passing score) on the first attempt. Students with no previous nursing course failures (note: according to the progression policy, students with 2 course failures cannot progress in the nursing program) are qualified to retake integrated clinical concepts. Those who are identified as having a high risk for failure on the exit examination may be advised to withdraw before the midterm to provide the necessary preparatory remediation study time. The faculty mentors determine risk for failure based on classroom performance, homework assignments, specialty examination score averages, and the number of Cs in clinical nursing courses.
Occasionally, students without a previous course failure fail the NCLEX simulation exit examination on their first 2 attempts. These students are allowed to retake integrated clinical concepts. When retaking the course, they work one-on-one with an assigned faculty mentor. They study, take additional practice examinations, and have 2 additional opportunities to pass the exit examination to graduate. In the end, it is clear that students who are supported by the faculty will strive to meet course outcome expectations and be successful.
Closing Gaps in the Curriculum
In 2003, the curriculum committee initiated the process to identify gaps in the curriculum. The gaps were defined as category scores that were less than 850 on the HESI exit examination. The gaps were identified for all cohorts who took the exit examination using a spreadsheet with class averages on each of the categories. The categories used by HESI exit examination mirror the NCLEX examination. Next, the faculty examined syllabi and course content to ensure effective and comprehensive coverage of identified curriculum gaps. As a result, student scores in the identified categories are rising; the gaps in the curriculum are closing.
Systematic Course Analysis
One of the initial strategies was to institute a systematic course analysis for all courses in the undergraduate curriculum. The faculty mapped individual syllabi to the program objectives to identify strengths and weaknesses in individual courses and across the curriculum. The faculty also mapped all teacher-made test questions against the NCLEX test plan to make sure that all content areas were covered in course lesson plans. As a result of the analysis, changes were made to course content. Subsequent to the implementation of course modifications, some lead faculty began to trend course data over time to analyze student outcomes. Examples of trended data include a comparison of student performance on teacher-made tests with standardized tests, the number of students who had repeated a nursing course, and evaluation results for classroom and clinical settings. The faculty have also identified NCLEX test plan subcategories pertinent to an individual course, and they are trending student performance over time using the subscores on standardized tests.
Supporting the Nursing Faculty
Support for the scholarship of teaching and learning by academic leadership is crucial to a successful program outcome process. Rapid change within the nursing program during the time period between 2002 and 2003 required additional support from the faculty. The nursing faculty received support in a number of ways. There were workshops to learn/update skills on the use of testing statistics to improve the quality of teacher-made tests. The faculty collaborated during academic retreats to examine course syllabi, correlate learning content to program objectives, and map test items to the NCLEX test plan. Many of the faculty attended an intensive workshop on teaching and learning assessment. The faculty were provided with reference resources such as Morrison's book, Critical Thinking and Test Item Writing Strategies, to assist with the development of teacher-made tests that address critical thinking.
Examining Program Admission Requirements
The Admissions and Progressions Committee scrutinized the nursing program admission requirements. The admissions criteria were amended several times after an analysis of student outcomes. As of fall of 2006, students are accepted to the nursing program using a formula that includes the student's grade point average, SAT, and Nursing Entrance Test (NET)8 scores. Changes were made to raise the prenursing grade point average admission requirement and include a pharmacology course as a prenursing core requirement. The results of these changes are promising; however, the faculty will not fully evaluate the outcome for 2 years when the students complete the nursing program.
Lessons Learned
The changes in processes and procedures have provided many lessons learned. The nursing faculty, students, and other stakeholders are extremely pleased with the positive changes in student outcomes over the last 6 years. The faculty are successfully developing data-driven incremental multidimensional processes and procedures that positively impact the teaching and learning process. The faculty have learned that a reasonable progression policy can dramatically improve student performance. Student feedback has facilitated the process of making changes at the course level. Providing the faculty with tools and skills to improve the quality of instruction and testing improves student outcomes.
Data-Driven Incremental Changes
The progression policy can make a significant impact on improving student performance. Small incremental changes using data-driven decisions can allow the policy to develop and meet the needs of the nursing program over time. The faculty can expect students to react to a change in a progression policy with anxiety and complaints; however, if the faculty listen and support the students, the fears can be minimized.
Student feedback can provide critical aspects in making the change process successful. For example, student feedback has guided the faculty in course construction and assessment of course outcomes. Students asked the faculty to provide significant credit for specialty HESI examination scores and use the HESI as a final examination. Students studying for the exit examination have requested opportunities to retake specialty examinations to assess their learning. The faculty who have been able to adopt those student recommendations in their courses have seen a dramatic improvement in student learning outcomes.
Deliberate Teaching Process
The faculty learned to make conscious choices in the teaching process to maximize student learning, for example, addressing multiple learning styles of students in the teaching/learning process, using case studies to assist with critical thinking, and using multiple assessment techniques to monitor the learning process and adopt teaching approaches. Examples of assessment techniques used in the integrated clinical concepts course include the think-aloud strategy and the muddiest point.
Student achievement is a complex process that involves trusting the advice of the faculty, using learning styles, understanding how to approach multiple choice questions written at the critical thinking level, and recognizing strengths and weaknesses of nursing knowledge. Students who are challenged to score as high as possible on all examinations rather than to pass at the minimum passing scores are more likely to succeed. Predictors for success on an exit examination will be program specific. Students should be guided to use their personal prediction score based on program-specific variables as a starting point to prepare for the exit examination.
Opportunities for Process Improvement
Engaging in nursing program outcomes process improvement has allowed new questions to surface.
What are the best predictors of student success? In our experience, the predictors have continually changed as a result of processes and procedures implemented to improve learning outcomes. Are we monitoring the best predictors?
What is the best way to store predictor variables? Hamner and Bentley9 used an academic database with course summary data. What advantages, if any, will a nursing program academic database have over the university academic database?
Should the faculty document a summary course analysis using a standardized format? Should all lead faculty be required to analyze course information using data over time? If so, what software would be most effective? How should the data be organized for aggregation and retrieval?
Conclusion
Evidence-based decision making can dramatically improve NCLEX passing rates. Although the actual strategies may vary, the process is one that may be applicable to other nursing programs. We recognize that there is no magic bullet to provide assurance to students that they will pass the NCLEX on the first attempt. We also realize that our passing rates may vary slightly. However, if our NCLEX passing rates dip again, the faculty will be ready to assess, diagnose, and modify current strategies to facilitate student success.
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