With the BSN degree identified by nursing professionals as the desired entry level into practice, there has been growing impetus for diploma and associate degree graduates to enroll in degree-granting nursing programe. Of the 1,401,633 registered nurses holding active licenses to practice in this country, 929,194 (67%) hold diplomas as their highest nursing-related educational credential and 154,180 (11%) have an associate degree (Moses & Roth, 1979). John Vaughn (1980), Director of Annual Surveys, Division of Research, National League for Nursing, reported that enrollment of RNs in baccalaureate programs increased by 75% in five years, rising from 15,854 in 1975 to 28,033 in 1979. Despite this increased enrollment, however, the proportion of RN students actually obtaining the BSN degree has not significantly increased (4.2% in 1975 to 4.3% in 1979). The reasons for the discrepancy between the number of enrollees and small number of graduates are numerous.
McGrath and Bacon (1979) discuss a variety of reasons why many diploma and associate degree students find working towards the BSN degree difficult. These reasons include inaccessibility of programs, problems with transfer of credits from lower division courses, on-campus residency requirements, and full-time student status. When an RN student finds an accessible program, matriculation into the upper division courses may be difficult. Sometimes challenge exams are offered; however, they often test theoretical knowledge more than clinical expertise. Since the RN student has often developed valued clinical skills, an examination covering both areas provides the most comprehensive testing package. Such a testing package attracts the RN student to seek enrollment and assists her in completing the program.
There are program changes currently under consideration at Duke University School of Nursing which might alter the challenge process described in this article. However, as faculty members of this school, we are interested in sharing selected aspects of our challenge examination process implemented for the past few years, which we believe facilitate the RN both to enter and complete the program. We will describe some of the activities of our examination in general terms rather than specific details since we believe a challenge examination must reflect both a specific curriculum and faculty expectations. The examples we have included from Duke's program are given to stimulate creative thinking within other faculty groups, who are developing both didactic and clinical challenge examinations. The description of clinical performance examinations by Carrie Lenburg, Coordinator, Regents External Degrees in Nursing, University of the State of New York, stimulated our faculty to design this RN challenge examination.
Our challenge examination process addresses the plea of registered nurses for recognition of prior education and experience. The process also ensures maintaining a quality educational program with an emphasis on self-directed learning. This particular challenge system evolved from our integrated curriculum, a curriculum that is based on general systems theory focusing on the nursing process skills. The two-year upper division nursing program at Duke is built on the natural and behavioral sciences and the humanities. Theories, concepts, and nursing skills are introduced during the junior year and further developed during the senior year. Broad health care concepts, rather than courses based on the more traditional medical model, are presented throughout the required nursing courses. These concepts are appUed and practiced in a variety of community and hospital settings. Our integrated curriculum design allows for flexibility in learning situations for students; this feature is particularly helpful for the RN student.
Admission to Duke University and to the School of Nursing for both generic and RN students occurs at the freshman level or at any point prior to the junior year for those students with transfer credits. Admission is offered after individual evaluation of each application.
After the registered nurse student completes the lower division requirements, she is eligible to take the challenge examinations for the four required junior level nursing courses. (These four courses are equivalent to 18 credits in most colleges and universities.) The purposes of the exams are to recognize and to give credit for knowledge, skills and attitudes that the RN students have obtained through previous education and work experiences. The design, timing, and general format of the challenge process has been developed as an opportunity for the RN student to demonstrate competencies, not as a guide to what she should learn.
The Process Begins
A spring orientation program is offered to those RN students interested in the challenge process. The purposes of this all-day meeting are to describe the philosophy of the School of Nursing and the curriculum framework, and to familiarize these students with the challenge exam process. Each student receives copies of the syllabi for each of the four courses being challenged, and specific materials related to the exams. These include the testing schedule, the instructions and criteria for the exams, and the clinical evaluation tools. Identical materials are mailed to those unable to attend the orientation program. The orientation day also includes discussion of the value of self-directed learning, content of the junior year course syllabi, and work and living opportunities. Following a meeting with current RN students, the challengers briefly tour the Medical Center Library and a clinical exam site in an inpatient setting.
During the orientation day a faculty member explains the evaluator role as that of a non-participant observer collecting data on the challenger's performance. As stated by Morgan, Luke, and Herbert (1979), "During evaluation the student and evaluator concentrate on the behaviors that indicate attainment of the defined criteria." In addition, the evaluator assesses the knowledge of the challenger through her oral and written responses.
The faculty views this day as the beginning of the resocialization process for RN students; therefore, the students and faculty explore the concept of role transition. To assist this process, RNs are invited to participate in an ongoing faculty-led support group during the next academic year. According to Muzio and Ohashi (1979), RN students undergo a process of role change during which prior values, norms, and standards must be rejected before new roles can be assumed. The support group in our program has been an integral part of our approach. This important resocialization process assists in resolution of the transitional conflicts and enhances the RN students' integration into baccalaureate nursing.
Following the orientation each RN challenger selects a one-week examination period during June or July. One experienced Duke faculty member evaluates the RN challenger during the week-long examination. A fee is charged for the exams; the major portion of this fee reimburses the faculty for the five-day period. The students are responsible for their own travel and living expenses during the examination week.
Description of the Examination
Congruent with the fall semester content of the junior year, the first set of activities tests the challenger on the integration of selected theories and concepts through assessment of well individuals from varying age groups. The criteria estabUshed for successful completion of the challenge examination reflect the same level of proficiency required of the generic students. The first activity of the examination focuses on an interaction with a four-yearold child in a day-care setting. This evaluation includes assessment of the challenger's communication techniques, physical assessment skills, and knowledge of growth and development. At the conclusion of this activity, the challenger verbally compares the assessment data with estabUshed growth and development norms, and evaluates her interaction with the child.
In the next activity, the challenger views a short videotape interaction between a nurse and a cUent after which she responds to written questions on communication techniques, coping mechanisms, and behavioral responses. During the third activity, the chaUenger completes a nursing history with an elderly client in a community setting, and then describes the impact of the suprasystem on this individual, and analyzes the cUent's health status using a bio-psycho-social framework.
To demonstrate knowledge in the concurrent theory course, the challenger completes a written, objective examination based on a sampling of questions from the theory exams used with the generic students. At the end of the second day, the faculty evaluator determines the examinee's pass/fail status and provides feedback on her performance. Unsuccessful completion of an examination means the chaUenger must take the failed course with the generic students in order to advance to the next course. Students may challenge each of the four junior level courses only once.
The third day begins the examination of the two second semester courses which focus on the individual experiencing illness. Evaluation occurs through an openbook case study and two inpatient experiences, and culminates in a formal clinical paper applying theories to a specific patient. The evaluator selects the first of the two inpatient experiences according to specific criteria which reflect second semester content and skills. The challenger interacts with the patient the evening before the actual examination and prepares a plan of care following exam material guidelines. On the next morning the chaUenger presents the individualized plan of care to the evaluator. The evaluator observes the challenger's physical assessment skills and nursing interventions as well as such items as patient safety and privacy, communication with family and patient, and prevention and control of infection.
That afternoon the challenger revises the care plan, evaluates the nursing interventions as planned or instituted, and submits the completed plan for evaluation. In preparing for the last day of the exam process the challenger returns to the same clinical setting and chooses a patient exhibiting characteristics and nursing problems different from the first patient. On the next day the evaluator observes the chaUenger caring for this second patient. The chaUenger discusses the application of two selected theories to the care of this patient. If specific competencies cannot be demonstrated through the patient experiences, simulations are arranged. Another testing modality is an open-book case study which again focuses on particular theories and knowledge. Because demonstrations of the ability to write a formal paper using theories is a junior year expectation, the challenger completes a short clinical paper. A written objective exam based on the second semester theory content completes the exam activities.
Our experience with competency examinations has provided us with useful information for assessing the effectiveness of this approach in the evaluation of registered nurse students in an integrated curriculum. Many aspects of the evaluation process have proven to be advantageous to the registered nurse students and faculty. Some of the major advantages for the RN students include: (1) selection of a specific evaluation week which enables each student to plan for the experience ahead of time, (2) provision for individualized evaluation with one faculty evaluator per student, (3) distribution of course syllabi and evaluation guidelines well in advance of exam date, (4) receipt of individual credit for successfully challenging each course, and (5) reduction of tuition expenses and time spent in the nursing program for the successful challengers. The School of Nursing faculty consider it advantageous to: (1) assure achievement of course objectives at the same level as the generic student before course credits are awarded, (2) utilize evaluation criteria congruent with our program, (3) assess individual learning needs of each student, and (4) recommend the placement of RN students in the senior year based on their learning needs.
Several aspects of this evaluation process might be viewed as negative factors. Because a faculty evaluator can be involved with only one student for an entire week and because the process occurs during the summer when many faculty are not teaching, it is difficult to secure the necessary number of faculty to act as evaluators. Additionally, the experience is intense and demanding for both students and evaluators because of the number and depth of evaluation activities completed within a five-day period. Finally, there is a financial obligation to the out-of-town RN student who needs to pay for travel and living expenses during the evaluation week.
in summary, our experience with competency examinations in evaluation of registered nurse students has been very satisfactory. These faculty-constructed tests reflect the philosophy, conceptual framework, and course objectives of our undergraduate program. The process provides opportunities for the faculty to observe clinical skills, and, therefore, directly evaluate the achievement of clinical course objectives. Likewise, students can demonstrate specific proficiencies in a variety of settings. Therefore, the credit received through the challenging process is comparable to the credit earned by generic students. Once the student challenges successfully she is able to enter the senior year with the same required competencies as the generic students. We are convinced that competency examinations encourage enrollment and promote successful completion of the BSN program.
- McGrath, B., & Bacon, T. (1979). Baccalaureate nursing education for the R.N.: Why is it so scarce? Journal of Nursing Education. 18(6), 40-45.
- Morgan, B., Luke, C, & Herbert, J. (1979). Evaluating clinical proficiency. Nursing Outlook, 27(8), 540-544.
- Moses, E., & Roth, A. (1979). Nursepower: What do statistics reveal about the nation's nurses? American Journal of Nursing, 79(10), 1745-1756.
- Muzio, L., & Ohashi, J. (1979). The R.N. student - unique characteristics, unique needs. Nursing Outlook, 27(8), 528-532.
- Vaughn, J. (1979). Educational preparation for nursing - 1979. Nursing and Health Care, 1(2), 80-86.