According to a 1978 California Board of Registered Nursing survey, only 10%-20% of foreign educated nurses pass the state board examination the first time while 85%-95% of United States graduate nurses do so. Why is there such a discrepancy? Is it that the foreign educated do not know the content? Apparently not. From those giving state board review courses, the problems lie elsewhere. For example, the survey indicated that 83% of the foreign educated had difficult with communication skills, 82% were unaccustomed to multiple -choice questions, 80% did not make decisions about patient care, and the most to least difficult exams were psychiatric, pediatric, medical, surgical, and obstetric nursing. Graduates taking review classes reported similar results. Of the 237 participants in this group, 161 (68%) said they read and understood English but needed more time to answer all the questions; 157 (66%) had difficulty understanding the American vernacular; 152 (64%) expressed having trouble with therapeutic communication, and 120 (50%) could not find a quality review course that met their needs. The participants also reported having difficulty with the exams in the same sequence as indicated above, i.e., 170 (72%) agreed that psychiatric nursing was hardest, 84 (35%) said pediatrics and 82 (35%) that medical nursing were next with 59 (25%) checking surgery, and 38 (16%) marking obstetric nursing as least difficult (A Study to Identify Problems, 1978).
The purpose of this article is twofold. The first is to illustrate ways that state board examinees can improve their test taking ability. The second is to provide potential instructors of state board review courses with knowledge and methods that work, which they can employ in assisting their students to pass. Our primary examinee target is the foreign educated nurse who is preparing to take the RN State Board Examination in the United States. However, the principles apply to American educated nurses as well as to any testing situation. Included in this paper is (1) content on study habits, (2) test taking techniques, (3) theories supporting the stress reduction that occurs in test situations, (4) survival techniques to utilize during testing and, finally, (5) a methodology of presenting this content to potential state board examinees.
In studying for an exam, good habits are imperative. It is important to formulate a schedule which ensures that some time is spent on every topic. Students naturally spend the most to least time on the most to least difficult subject for them. Reading with a questioning mind is essential to acquire knowledge. If books are not available that contain questions with answers at the end of each chapter, or unit, the student should develop her own questions. The Cornell system is often used to accomplish this goal. The advocated technique is to employ the title of a chapter to formulate main questions. The subheadings in the chapter are utilized to develop subsidiary questions. When chapter subheadings are few, each page should be divided into subheadings by the student. The developed questions direct the student's reading. After studying the chapter, the student should answer the questions in her own words. This should be done even when the book provides questions and certainly before the student looks at the answer given in the book. When the student's answers are incorrect, further study of that content is obviously needed, and perhaps from a different perspective or even another text.
Test Taking Techniques
There are at least three factors that are important to consider in the overall strategy of taking an exam. Knowing these assist students to answer questions correctly that they may otherwise miss. These factors include vocabulary review, question analysis and simulated practice.
Vocabulary Review: When a test is handed to an examinee, initial behaviors consist of scanning the material for length, type, and number of questions. Prior to answering any questions, the student should identify the unfamiliar words in the questions and in the provided answers in a multiple choice exam. In utilizing this method in studying for the exam, the following is advocated. List the unfamiliar words on a separate piece of paper. Examine their root, prefix and suffix. Using this method of vocabulary analysis often enables the individual to determine the meaning of the word, or a proximity thereof. This assists the student to understand the question and to select the best answer. Without understanding the meaning of the words, many questions are misinterpreted and many wrong answers are given as a result. This technique is of value to Americans, of course, as well as to the foreign educated.
Foreign educated nurses also have difficulty with idioms or vernacularisms. Some of them complain that although they read and understand the English language, they have trouble with idioms which apparently are often used in test situations. Although it is an added burden, they must acquire familiarity with colliquialisms just as they would any other vocabulary. A good method is for them to learn the new words when they are encountered in their social and professional contact with others, in their everyday reading and in studying for the exam itself, of course.
Question Analysis: Prior to analyzing a question in search of the best answer, an overall aproach to keep in mind is to read the question and if the examinees do not know the answers, they may put a fight pencil mark in the margin at that point and continue on. This enables them to answer many questions that they do know in the time alotted. Also, in subsequent questions and answers, they may acquire enough information to answer previous questions. After answering all the questions they readily know, they should then return to the more difficult questions and attempt to answer them.
Examinees should do the following when taking a test.
* Check the question for pronoun referents, i.e., when the question refers to the former and to the latter. Although these are not intentionally trick questions, the student must clearly understand what the former and the latter refers to in order to answer the question correctly.
* When split statements are made, the first part is true. The answer that completes the statement must be gramatically equivalent.
* When absolutes, such as never, always and only are utilized in the possible choice of answers, they are usually not the correct answer or best selection.
* The answer must correspond to the specifics in the question being asked. For example, if the question asks how to control behavior and this is discussed, then the answer also addresses the subject of control of behavior.
* The longest answer is often correct because it provides the most precise information.
* If a debate between two possible answers occurs, the most correct one usually contains a broader, more general statement.
An overall thought to remember is that nursing is primarily concerned with the subjective symptoms rather than the objective ones. In many questions, the content in the answers focuses on feelings, acceptance of the patient, developing good patientnurse relationships, etc. These answers are often the best choices. However, the nurse must be aware that although she may accept a patient's feelings, she does not necessarly accept his behavior.
In general, when the nurse is unsure which is the best of two possible answers using the strategies given above will be helpful in making a decision.
Simulated Practice: There are two important strategies which are helpful for nurses to practice prior to taking the exam. One is to drill themselves under timed conditions and the other is to practice relaxing to decrease anxiety.
Timing: The purpose of the drill under timed conditions if done frequently enough, will accomplish the following. First, it will convince the individuals that they can answer a relatively large number of questions in a short period of time, which in itself is valuable. Second, if they continue to vary the questions that are used with each practice session, they will increase their knowledge of the content. Third, and perhaps most important, as they positively reinforce their self-concept with repeated success in simulated situations by answering many questions correctly, they will become confident that they will be successful in the actual test session.
Relaxation Techniques: Many approaches can be employed by individuals which enable them to relax in a stressful environment. Among these are distraction, cutaneous stimulation, relaxation techniques, per se, and imagery. Before briefly discussing each of these, some general guidelines which relieve stress are included here. (1) The individual needs to be aware of, and utilize, a variety of stress relief measures. (2) These measures should be initiated before the stress becomes intense. (3) Know what measures are most effective for an individual, or oneself, and use these frequently. (4) If a stress relief measure is ineffective at first, try it several times before abandoning it. (5 ) The individual should be open minded about what will relieve the stress and try several approaches often until a suitable measure is identified (McCaffery, 1979). (6) And remember that although we cannot control the stress, we can control the response to stress and that with practice these techniques or responses can often be accomplished in a few seconds.
Distraction is the act of diverting the mind or attention. It serves to protect an individual from stress by focusing on thoughts unrelated to the stressful situation. If distraction has been used in the past, an individual may find the same device will work again. If it has not been used, it can be by identifying the interests of the individual and by using them as distraction devices.
Most people cannot use distraction for a long period of time or as the only measure to relieve stress. It is necessary, therefore, to know and use other techniques as well. If stress becomes intense, an individual should increase the complexity of the distraction but only within limits. If the stress reaches an intense peak, less complex distractions work best. The effectiveness of the distractive technique is enhanced when several sensory modalities are used including hearing, touching, seeing and moving, and when a rhythm is utilized particularly when the focus is on breathing, for example. On the other hand, the individual should avoid external or mental stimuli that remind her of the stressful situation.
Some specific distraction strategies that can easily be used in test situations include slow rhythmic breathing, humming or singing to oneself and tapping the rhythm. Another technique that works is describing a series of pictures to oneself (McCaffery, 1979).
Cutaneous stimulation combines trial and error with common sense. The individual's perception of relief, or no relief from stress, should be the guide for use of the technique employed. The types of stimulation that can be used in a test situation include pressure and massage. The frequency and duration of the stimulation is determined by how long the relief from stress persists following the stimulation. It may last only a short time or for several hours depending to some extent on the individual. The areas of the body most often used in cutaneous stimulation are the sites where the response to the stress is felt, e.g., the forehead. However, application of pressure to skin areas unrelated to the stress response site may work equally well for some (McCaffery, 1979).
Relaxation techniques which are practiced provide individuals with some selfcontrol in regard to their response to stress. This helps decrease the anxiety that accompanies stress. Although numerous relaxation methods can be identified, many of them are similar or a combination of two or more approaches. Some of the various techniques include meditation, biofeedback, yoga, zen, autogenic training, self-hypnosis, imagery, art, music, and dance.
With all of these, concentration is important to accomplish the goal. In meditation, it is necessary to focus on breathing slowly, for example, or on some other task. In autogenic training, repeating phrases silently are used, such as my right arm is heavy, or my left leg is warm. Breathing may also be one of the exercises practiced. The goal of biofeedback is to gain and maintain control over a body function and then utilize this ability in stressful or adverse conditions.
Some of the positive effects of relaxation include a decrease in anxiety, a reduction in stress, an alleviation of muscle tension that may cause stress or pain, and an increase in the effectiveness of other stress relieving measures (McCaffery, 1979). Factors that enhance a relaxation response are a quiet environment, a comfortable position, a positive attitude, using known methods that work for an individual, and accompanying the relaxation technique with muscle tension perception. The latter two go hand in hand.
Imagery may be defined as the ability of an individual to develop images that involve all of the senses including sight, smell, hearing, taste, touch, and movement (Kroger & Fezler, 1976). Initially, it is important to identify how persons use their imagination. They must be able to concentrate, follow directions, and respond to suggestions of images. It is helpful to utilize images that are known to the client, and essential to employ one total image at a time. Precede the imagery with one of the relaxation methods discussed above. Describe the image that is to be conveyed in positive and soothing terms. Practice the technique until skillful with it and determine in advance the duration of this activity so it can be ended at a set time. Although this technique is usually used with a patient, or client, it can be employed by others for their own purpose.
Theories Supporting Stress Reduction
There are currently at least two concepts that explain why relaxation techniques work, namely, gate control theory and the endorphin theory. The following simplified and condensed discussion is adapted from an article by West (1981).
The Melzack-Wall gate control theory assumes that sensory nerve impulses, e.g., tension or pain from stress, travel from nerve receptors to synapses in the spinal cord. The synapses serve as gates which when open permit impulses to be transmitted to the brain but when closed block the passage of the impulse. The kind of impulses bombarding the gates determine whether the gates open or close. When thick fiber impulses (from touch or pressure) predominate, the gates close on thin fiber impulses which conduct pain. The result is that the pain message does not reach the brain. In addition, the brain can inhibit pain impulses that pass through the synaptic gate and thus control the reaction to pain. It is thought that this is possibly due to descending impulses mediated by endorphins.
Endorphin is a word derived from endogenous and morphine. It is an opiate-like peptide. It is believed that opiate receptors in the brain relieve pain by altering the perception of pain rather than preventing it. Research on endorphins indicates that endorphins are found in synapsis between nerve fibers. Their function is to transmit, inhibit and modify noxious stimuli. As a result, they may relieve pain as evidenced by the fact that endorphin levels are high after pain relief. It is thought that endorphin release may be necessary for the success of most types of pain relievers. They appear to affect the psychological components of pain and reduce anxiety which is known to increase the perception of pain.
Implications for State Board Examinees
Although it is easier for some to attend a class and involve themselves in a guided experience, others may prefer to use available knowledge, e.g., that given above, and study alone. For the former group, we offered a one-day seminar for nurses preparing to take the state board examination. The seminar was scheduled biannually and has been given on two occasions. Twice as many participants attended the second time it was offered which was just prior to the state board examination. Although foreign educated nurses constituted the majority of the audience, several Americans who had difficulty with test taking, attended also. The positive response to this seminar indicated a need of these nurses was being met - a need that related to their poor test taking ability.
In formulating the seminar content, we considered the results of the California survey discussed above and also the following. Allen (1980) reported that in teaching a psychiatric nursing course to foreign educated students, they scored good to excellent on theoretical knowledge but only fair to good on reading comprehension. The latter is perhaps due, in part, to limited knowledge of vocabulary. Sweeney (1973) observed that foreign educated nurses were conscientious in their work but were hesitant and shy with directing the work of others in the delivery of care to patients. Barnes (1980) found that in teaching psychiatric nursing to foreign educated nurses, they rarely asked questions in large groups but did so in small groups and on a one-to-one basis. Barnes also noted that these students had difficulty with theoretical language and its everyday use in the medical field, and that their own cultural beliefs and values influenced them strongly in selecting their answers to questions. Morrison (1980) similarly observed that foreign educated nurses often missed multiple-choice questions because they were unfamiliar with American terms and games that are used in the answers. Furthermore v one student reported that it was considered rude in her country to inquire about a person's feelings. In this country, we focus heavily on this content not only with the patients but also with the student nurses.
In the content presented, we selected examples that called for the directing of others in work settings, We used small groups which encouraged discussion among the participants and with the faculty. Our quiz questions employed the vernacular and were analyzed to assist the nurses in grasping the meaning of words. And we gave numerous examples that dealt with the feelings of patients and nurses. Although our focus was on test taking, some content was naturally included in our question and answer examples.
An overview of our test comprehension day was as follows. In the morning session, content was presented on study habits, question analysis and vocabulary analysis. The participants took two exams. The first was short and taken by each individual, while the second was longer and was a small group effort. After each of these, the questions and multiple-choice answers were reviewed in detail for vocabulary analysis and for question analysis. The rationale for each answer was explained and discussed at length. In the afternoon, some relaxation techniques were presented and practiced. This was followed by a long, simulated state board examination in which there were content questions from all nursing areas, as was the case in the morning. All the exams were timed tests. At the end of the day, selected questions and answers were again given and discussed. The student feedback indicated that the course was helpful and well received.
When good study habits, scientific testtaking techniques with rationale, and methods of relaxation to utilize during examination periods are known and employed, more state board examinees will successfully pass this test.
- Allen, M. (1980). The problem of communication in a summer workshop for foreign nurses. Journal of Nursing Education, 19(1), 8-11.
- Barnes, S.Y. (1980). Problems foreign nurses encounter in passing psychiatric nursing on U.S. exams for licensure. Journal of Nursing Education, 29(1), 19-25.
- Kroger, W.S., & Fezler, W.D. (1976). Hypnosis and behavior modification: imagery conditioning. Philadelphia: J.B. Lippincott.
- McCaffery, M. (1979), Nursing management of the patient with pain (2nd ed. ). Philadelphia: J.B. Lippincott.
- Morrison, B.L. (1980). Conflicts and frustration influencing nurses from other countries. Journal of Nursing Education, 191), 12-18.
- A study to identify problems ofnon-U.S. graduate nurses taking state board licensing examinations. California State Board lest Pool Exam Survey, 1978.
- Sweeney, V.K. (1973). Working with nurses from other countries. American Journal of Nursing, 73, 1768-1770.
- West, B.A. (1981). Understanding endorphins: Our natural pain relief system. Nursing 81, 22(2), 50-53.