May 5, 2007
Facilitating Program and NCLEX-RN Success in a Generic BSN Program
By Uyehara, Janet; Magnussen, Lois; Itano, Joanne; Zhang, Shuqiang
This article focuses on a study of predictors of program and NCLEX-RN success and withdrawal in a generic BSN program at the University of Hawaii at Manoa School of Nursing. Data were collected over a 5-year period after a new curriculum was implemented. High program (95.09%) and NCLEX-RN (97.25%) success were achieved. Of the 11 who did not meet the definition of program success, 100% completed the program by another two to three semesters and 90.91% passed the NCLEX-RN as first-time takers. The program withdrawal rate was 20%. It is very important to use measures to promote program completion and NCLEX passing for both the normally progressing and at-risk student to meet the demands of the nursing shortage.Search terms: NCLEX-RN, predictors of success, student attrition, student retention
In recent years, much has been written about the factors that influence nursing student success in completing a program and ultimately passing the national licensure examination, NCLEX. Recent reports show that a serious shortage of nurses is now a reality. Buerhaus, Staiger, and Auerbach (2000) predict that by the year 2010, 40% of working registered nurses (RN) in the United States will be over age 50. Clearly, it is important for educators to evaluate methods of selecting, educating, and retaining students who will become the professionals of tomorrow.
This article describes a study that was conducted at the University of Hawaii at Manoa School of Nursing that focused on predictors of NCLEX-RN passing and program success and withdrawal in the baccalaureate program in nursing. The study was undertaken after a new curriculum pattern was implemented to address serious concerns about program and NCLEX success in the previous curriculum. Data were collected over a 5-year period after the new curriculum was implemented and the resulting pass rate on NCLEX was very high.
Review of Literature
According to Shelton (2003), the desirable retention rate as set by the National League for Nursing Accrediting Commission in 1996 was 80%; however, studies (Ehrenfeld, Rotenberg, Sharon, & Bergman, 1997; Vance & Davidhizar, 1997) have reported rates of attrition for nursing students ranging from 20% to 41%. Glossop (2001) has noted that the reasons for attrition in the United States were (a) academic difficulties such as low course grades, (b) family or personal problems, (c) financial difficulties, (d) pregnancy or illness, and (e) dislike for nursing. Other studies (Beck, 1995; Hanson & Smith, 1996; Harvey & McMurray, 1997; Magnussen & Amundson, 2003; Spouse, 2000) have indicated other stressors that can affect student retention such as (a) burnout, (b) time pressure, (c) conflicting demands, (d) not-so-caring interaction with faculty, (e) feeling unprepared for clinical practice, (f) lack of support and respect from faculty and staff, (g) negative images of nursing, and (h) discrepancy between student perceptions and the actual nursing experience.
Over the past several years, various authors (Alexander & Brophy, 1997; Barkley, Rhodes, & Dufour, 1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; Briscoe & Anema, 1999; Campbell & Dickson, 1996; Gallagher, Bomba, & Crane, 2001; Itano & Zhang, 1999, unpublished; Potolsky, Cohen, & Saylor, 2003) have reviewed the relative significance of various measures in predicting student success on NCLEX. Important predictors have been found to be associated with data collected on admission, within the program, and at the end of the program.
Admission Data as Predictors of Success
In a 5-year study of NCLEX-RN performance from July 1988 to February 1994, Alexander and Brophy (1997) found that on admission, the SAT verbal score could identify a student at risk and was strongly correlated with future NCLEX-RN performance. Potolsky, Cohen, and Saylor's (2003) study found that prerequisite science course performance is a reliable predictor of academic performance in nursing. In another study of the appropriateness of two admission tests, Gallagher et al. (2001) found that the Registered Nurse Entrance Examination (RNEE) was a more reliable predictor of academic success in an Associate Degree nursing program than the Nursing Entrance Test (NET). In contrast, Sayles, Shelton, and Powell (2003) determined that composite scores on the NET and preRN were statistically significant and could have been useful in predicting success on the NCLEX.
Within Program Indicators
The findings of studies investigating withinprogram predictors of baccalaureate student success have not been consistent and cannot be generalized from one program to another. Barkley et al. (1998) and Alexander and Brophy (1997) found a strong correlation between passing NCLEX-RN and NLN scores on the Psychiatric, Adult Health, Mental Health, Obstetric, and Pediatric Achievement Tests.
Other researchers (Alexander & Brophy, 1997; Barkley et al., 1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; Itano & Zhang, 1999, unpublished) examined correlation between grades in specific nursing courses and NCLEX success. Courses identified as predictive of NCLEX outcome included Pathophysiology, Adult Health Nursing I & II, Mental Health Nursing, Maternal-Newborn Nursing, Pediatric Nursing, and Nursing Care of the Critically Ill. Significant correlations were also demonstrated between grades of C or below in certain nursing courses and low scores on the NLN Achievement Tests with risk of failure. Beeson and Kissling's study of 505 subjects reviewed the predictive value of grades, and found that on average, the odds of failing the licensure examination increased 56% for each additional C, D, or F a student received in nursing courses.
They also found that, for each increase of 10 percentage points on the Mosby Assess Test, the odds of failing were decreased by 150%. They reported that they were able to use progression status and grade achievement information to work with the students who were at risk for failing NCLEX-RN.
Nibert and Young (2001) report that the Health Education Systems Exit Examination (HESI), taken at the end of a nursing curriculum, is highly accurate in predicting NCLEX success. Morrison, Free, and Newman (2002) describe a study that analyzed the effects of a progression policy, implemented at five schools of nursing, that withheld graduation or permission to take NCLEX until the student had obtained a designated score on the HESI E2 examination. Findings indicated that the pass rates increased significantly in six of the seven programs (two of the schools had two different types of programs) after the progression policy was implemented.
The purpose of this study was to identify the predictors of program success and withdrawal and NCLEX-RN passing from data collected at three phases of their matriculation in the school: admission, within the program, and at exit. Program success was defined as completing the program within one semester of expected completion. For example, a student who was admitted in fall 2000 was normally expected to complete the program in spring 2003. The student was classified as successful if the student completed the program by fall 2003. NCLEX-RN success was defined as receiving a pass score on the NCLEX-RN examination on the first attempt. Program withdrawal was defined as leaving the nursing program before graduation.
The sample consisted of 280 generic baccalaureate nursing students who were admitted to the 3-year (six semesters) baccalaureate curriculum over a 5-year period. Each admitted student was tracked until the student withdrew or graduated from the nursing program. From the 10 groups of admitted students in that time period, data collection was completed for 224 students who graduated from the program. For 56 students, data collection was completed only until they withdrew from the program.
The dependent variables were program success and withdrawal and NCLEX-RN passing. Both have been defined in the above paragraph. The independent variables included pre-admission, within program, and end of program predictors. The pre-admission data were prerequisite GPA, cumulative GPA, NLN pre-nursing verbal, math, science, and composite scores, and ethnicity. Within the program data included grades from the Pathophysiology, Fundamentals, Adult Health Nursing I, Mental Health Nursing, Maternal-Newborn Nursing, Pediatric Nursing, and Adult Health Nursing II courses, the NLN achievement test scores for mental health, childbearing family, pediatric nursing, and adult health nursing, and the Watson Glaser Critical Thinking Appraisal. The end of the program data were the Mosby Assess Test score and the nursing GPA at graduation. Data analysis included descriptive statistics, correlations, and regression analysis to determine possible relationships between the dependent and independent variables.
During the data-collection period, 280 students were admitted to the program. The sample was predominately female (N = 230, 82.1%) and 17.8% (N = 50) were male. Their mean age was 24.63 years with a range of 20 to 47 years. Ethnic breakdown of the sample is shown in Table 1.
Of the 218 with reported NCLEX results, 97.25% (212) reported passing the NCLEX on the first \attempt. This group was 82.57% (n = 180) female and 17.43% male (n = 38). Their mean age was 24.40 years (range 20 to 47 years). Significant correlations were identified between NCLEX-RN success and the Mosby Assess Test (N = 216, r = .24, p = .0003), the NLN Adult Health Comprehensive Test (N = 217, r= .41, p
Of the 224 students who completed the program, 213 (95.09%) met the definition of program success while 11 (4.91%) did not. The group that did not meet the definition of program success were 81.82% (n = 9) female and 18.18% (n = 2) male; their mean age was 32.09 years (range 22 to 47). There were no significant correlations among the independent and dependent variables of this group and no significant predictors of program success and withdrawal and NCLEX- RN passing. Of these 11 decelerated students, all completed the program by another two to three semesters and 10 (90.91%) passed NCLEX on the first attempt.
Of the 280 students in the sample, 56 (20%) withdrew from the program. This group was 80.36% (n = 45) female and 19.64% (n = 11) male. The mean age was 24.83 years (range 20 to 42 years).
Of the independent variables, only the grades from the pathophysiology course is significant (N = 271, p
Based on a previous study (Itano & Zhang, 1999, unpublished), in which Filipino students had a statistically higher probability of NCLEX failure, the program withdrawal rate for non-Filipino students (19.19%) were compared to Filipino students (19.28%). There is no significant difference in their rates of program withdrawal, NCLEX passing, or program non-success.
During the data-collection period, 56 of the 280 (20.0%) students withdrew from the nursing program. The major reasons for withdrawing included academic failure (20/56, 35.71%), personal due to health problems or moving out of state (19/56, 33.93%), and career change (17/56, 30.36%). Further analysis indicates that 12.5% (7) withdrew in the first semester of the six-semester program, 10.71% (6) withdrew in semester 2, 48.21% (27) left in semester 3, 16.07% (9) withdrew in semester 4, and 12.5% (7) left in semester 5. Of the 16 students who withdrew during semesters 4 and 5, 43.8% (7) left for academic reasons, 31.3% (5) left for personal reasons, and 25% (4) left for a career change. Five students were not able to maintain the academic progression requirements of the program, three students were leaving this location, and the other eight students may have needed more support and counseling to be able to proceed in this program.
From this study, there were some interesting findings that have been useful in continued program planning and evaluation of the undergraduate curriculum as it relates to predictors of NCLEX-RN passing and program success and withdrawal.
Faculty speculated that the two major changes implemented in the new curriculum were factors that promoted program and NCLEX-RN success in this group of students. The curriculum was changed because of problematic results on NCLEX-RN that had occurred with the previous 2-year curriculum. The NCLEX-RN pass rate had intermittently dropped as low as 82% in various classes from a previously consistent rate of around 90%. In addition to rearranging the order of the nursing clinical courses to demonstrate progressive growth in complexity throughout the curriculum, the adult health content was increased from 8 to 10 credits and split into two courses. The second adult health course was placed in the fifth semester of the six-semester nursing sequence to ensure that this content was addressed close to graduation from the program.
An additional measure to address the poor results on NCLEX-RN was the implementation of an NCLEX review course for elective credit. Since the curriculum required two elective courses, students were highly encouraged to take this course in their final semester. Emphasis was placed on test-taking skills and repetitive questioning in the applied mode that is characteristic of the licensure examination. Most students in the study took this course. Although the literature shows that schools of nursing often encourage their graduates to take an NCLEX review course, this course possibly offers an additional benefit because it is conducted over the entire semester rather than just a few weeks, thus offering the additional element of learning content over a longer length of time.
Although some of the students in the study were born into immigrant families, most of the students spoke English as their primary language at home. The majority that spoke English as a second language were able to pass NCLEX on their first attempt. Of the six who failed NCLEX-RN, only one spoke a foreign language (Vietnamese) in her home. Although in Itano and Zhang's (1999, unpublished) earlier study, ethnicity was correlated with NCLEX-RN failure, ethnicity was not found to be a predictor of NCLEX-RN success in this study. In looking for reasons for this change, it was found that the majority of the students of Filipino ancestry in this study spoke English as a primary language.
Cunningham, Stacciarini, and Towle (2004) offer strategies to assist ESL students to take the NCLEXRN including early identification of ESL students having difficulty and the utilization of system resources to offer assistance. Suggested resources were language helps, including medical and nonmedical dictionaries and thesauri in English and tutoring. Other resources included offering repeated practice with NCLEX-type questions, psychosocial support, and encouraging the student to take a comprehensive NCLEX review course.
The only course that was predictive of NCLEX-RN pass rate on this study was the fundamentals course. While the pathophysiology course, a heavy science-based course, was a significant predictor of program withdrawal. Grades in the pathophysiology course have been correlated in other studies with program and NCLEX success as previously stated. Since these courses are taught in semester 2, they can be used to identify the student at-risk early in the program. Suggested measures for at-risk and culturally diverse students can then be implemented to facilitate program and NCLEX-RN success. Eddy and Epeneter (2002) show that faculty can assist students to, first of all, determine their readiness for taking the exam, and, later, develop appropriate test-taking strategies. Mills, Wilson, and Bar (2001) report a holistic program that provides a caring environment which promoted success on NCLEX.
Program Completion and Withdrawal
Out of the 56 students who withdrew from the program, 36 did so because of personal reasons and career change. Within this group, 12 students left because they moved to a new location. Of the 24 other students, 7 students had to deal with health problems (including anxiety) and 16 students wanted a career change in semesters 3, 4, or 5. These 24 students had a cumulative GPA of 2.76 to 4.00 with an average of 3.43. Appropriate counseling and support may have altered their decision to leave nursing. Faculty was also concerned about the 27 students who withdrew in semester 3. Discussion about faculty support for these students led to changes in the Adult Health I course that decreased the attrition in that semester. The students felt more caring from the faculty, which facilitated their retention in the program.
Of the three ethnic groups with the larger numbers (18 Filipino students, 14 Caucasian students, 9 Japanese students) who withdrew from the program, 50% (n = 10) of the Filipino students withdrew due to academic failure, 50% (n = T) of the Caucasian students withdrew due to personal reasons, and 56% (n = 5) of the Japanese students withdrew due to career change. By identifying and clarifying the reasons for withdrawal within an ethnic group, measures may be taken to facilitate their success in the program.
Two doctoral dissertations addressed measures that facilitated the academic progression and success of atrisk students and those from culturally diverse backgrounds. In Peter's (1996) study with at- risk students, the effective measures were (a) early identification of being at risk; (b) regular faculty advising; (c) learning strategies workshops on motivation, anxiety management, concentration, ability to select main ideas, and test-taking skills; (d) peer tutors; and (e) study groups. In Condon's (1996) study with nursing students of culturally diverse backgrounds, prevention of student overload, encouragement and support from caring nursing faculty, active involvement in learning, exam/ study skills, study time, promotion of social com\fort, providing financial assistance, and flexible policies were helpful for the student's success in the nursing program. Shelton (2003) provided evidence that both psychological and functional faculty support facilitated student retention by promoting persistence of the student toward completion of academic requirements. In other words, if a student perceived that faculty support was greater, this student was more likely to persist in completing the nursing program. Students who withdrew voluntarily or from academic failure perceived less faculty support. The caring attitude and environment made the students feel that the faculty wanted them to succeed in the program. These types of measures are necessary to facilitate program completion for the students who decelerate or consider withdrawal during their progression in the nursing program.
To meet the demands of the nursing shortage, facilitation of program and NCLEX-RN success are very important. Every nursing student should be viewed as a potential registered professional nurse and a muchneeded asset for the nursing profession. With this in mind, the greatest number of graduates would be realized if faculty could provide the knowledge, guidance, and caring not only to students who progress normally, but also to those who are decelerated and considering potential withdrawal.
In this study, a majority of the students had program and NCLEX success. Since the students had sufficient ability to have program and NCLEX success, the pre-admission predictors and the admission criteria were supported.
Of the 11 who decelerated and completed the program in a longer period (two to three semesters), 10 also had NCLEX success. The only major loss of potential graduates was the 24 students who withdrew from the program for personal reasons or career change. Efforts are now being made to work more closely with these at-risk students to facilitate their program success.
The study was undertaken to evaluate a new curriculum. The significant changes in the new curriculum included (a) a new 3-year (rather than 2-year) curriculum with progressive growth in complexity, (b) use of the pathophysiology course and the NLN Adult Health Comprehensive Test scores as risk factors for success, (c) the two adult health courses for 10 credits with one scheduled in the fifth semester, (d) changes in the Adult Health I course to decrease attrition, (e) an NCLEX review elective course in the sixth semester, and (f) a more caring and supportive environment. Another strategy used to facilitate student success is that students are now notified of being at risk or high risk based on the following: (a) their nursing course grades, (b) NLN or ERI achievement test scores, (c) Mosby Assess Test scores, and (d) nursing GPA. In this way, each student can prepare sufficiently on their risk prior to taking the NCLEX licensure exam.
Reviewing elements of the curriculum that predict student success facilitates the planning and implementation of appropriate teaching strategies. Since we desire to have as many graduates as possible while maintaining academic standards, measures should be used that would promote program completion and NCLEX passing for all students, including those at risk.
Other studies have indicated other stressors that can affect student retention such as (a) burnout, (b) time pressure, (c) conflicting demands, (d) not-so-caring interaction with faculty, (e) feeling unprepared for clinical practice, (f) lack of support and respect from faculty and staff, (g) negative images of nursing, and (h) discrepancy between student perceptions and the actual nursing experience.
They also found that, for each increase of 10 percentage points on the Mosby Assess Test, the odds of failing were decreased by 150%.
... if a student perceived that faculty support was greater, this student was more likely to persist in completing the nursing program.
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Janet Uyehara, MS, RNC, Lois Magnussen, EdD, APRN, Joanne Itano, PhD, RN, OCN, and Shuqiang Zhang, PhD
Janet Uyehara, MS, RNC, is Assistant Professor, and Lois Magnussen, EdD, APRN, is Associate Professor, Department of Nursing, Joanne Itano, PhD, RN, OCN, is Associate Professor and Director, Academic Planning and Policy, and Shuqiang Zhang, PhD, is Associate Professor, Department of Educational Psychology, University of Hawaii at Manoa, Honolulu, Hawaii.
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