Statement of Problem: The School of Nursing is one of five schools affiliated with a private Northwestern liberal arts college. The overall enrollment for the University is approximately 3000 students; slightly less than 200 students are enrolled in the upper division nursing major with a similar number completing Freshman and Sophomore prerequisite courses. The baccalaureate program in nursing at the University has been established for 50 years and accredited since 1949 by the National League for Nursing (NLN).
The purpose of this study was to evaluate student curricular experience while in the nursing major of an undergraduate baccalaureate program. Particular attention was given to first-time occurrence within a decade of unusually low scores earned by one-third of the 1983 graduates of the program on the National Council Licensing Examination (NCLEX).
Upon receipt of the NCLEX results, the Dean of the School of Nursing appointed a task force to evaluate the failure. The task force chose a Work Systems Framework as the design of the study in order to place the results of the 1983 NCLEX examination in a holistic perspective. The committee collected and analyzed opinion and profile data in the areas of students, faculty, and curriculum.
Many studies have been conducted over the last 20 years yielding predictors of undergraduate students* ability to perform on state board examinations given prior to 1982. It was not known whether these same predictors might be used to apprise student ability on the new NCLEX examination given since 1982. Prior studies indicated that high school performance, pre-college exams and college GPA were good predictors of success on State Board Test Pool Exams (SBTPE).
Pérez (1977) studied BSN graduates of a private liberal arts college similar to this university. She found that ACT scores were useful predictive variables. She also found that the ACT Social Science/Reading score was equal to if not more meaningful than the ACT Natural Science score. She concluded that GPAs in the area of social sciences might be equally as valuable as the GPAs in the natural sciences. Knopke (1979) found that first semester college GPA, high school percentile rank, and college qualifying test "science" subset were highly correlated with drop-out or retention. Outtz (1979) found that college cumulative GPA and verbal SAT scores were the best predictors of state board examinations results for Blacks.
Francis Siether (1980) reported biological sciences GPA to be a valid predictor of academic performance. The power of this prediction could be increased by adding social science GPAs. She found, however, that high school percentile rank was the best predictor of academic success in a school of nursing. Hayes (1981) asserted that the cognitive variables represented by class grades in math, psychology, chemistry, SAT verbal scores and philosophy were the most powerful predictors of later success on state board exams. In some, the ability to read and demonstrate above average academic performance through entrance and internal exams as reflected in pre-college and college tests as well as high school and college grade points were found to be the best predictors of success in state board testing situations.
The curriculum area of this research project also required a literature review to identify articles related to curriculum structure and student achievement. A limited number of articles were located. They reflected two general themes: 1) the need to re-think how we conceptualized the "integrated" curriculum, and 2) descriptions of problems experienced by schools with integrated curricula.
One of the major issues identified by Styles (1976) was that the term "integration" is used in a variety of ways. Many curricula which are termed "integrated" do not actually match the definition by Torres (1974, p. 2) that "integration" refers to "blending the nursing content in such a way that the parts or specialties are no longer distinguishable." Styles (1976) and Veith (1978) both pointed out that various types of curriculum organization can facilitate the goal of integration within the learner. It is not really the "curriculum" which is integrated; integration occurs in the mind of the learner and the curriculum and teaching should facilitate that occurrence.
Maloney (1978) reported that some of the problems with "integrated" curricula as perceived by deans and faculty were: 1) team teaching, 2) teaching in areas outside of expertise, 3) lack of continuity of teaching assignments, and 4) time requirements for team building and maintenance. Styles (1976) identified other difficulties with the "integrated" curriculum as being 1) special competencies of faculty may be suppressed, 2 ) time and energy commitment may detract from research special projects and other university/community service, 3) accountability is vague, and 4) courses, teams, and decisions can become ponderous. Styles (1976) identified some laudable outcomes of the pursuit of integration as 1) basing the curriculum on a framework, 2) use of a broader range of educational materials, and 3) experimentation with a variety of teaching learning strategies. The articles in general suggested re-thinking the approach to the integrated curriculum with the goal of assisting the learner to achieve integration. Veith (1978) recommended, in particular, teaching theory and practice concurrently.
Methodology and Data Analysis
Student Profile: Guided by the literature, the committee undertook to compile and study: 1) variables recognized as predictors of success on SBTPE from the University School of Nursing graduate population, and 2 ) the composition and delivery of the curriculum experienced by those graduates. Data consisting of 23 variables were collected from the student records of the class of 1983 and the class of 1982 (which had a 94% success rate) for comparison purposes. Separate analysis was completed for each class. Association with a particular class was not found to be significant. Therefore, 12 of the more significant variables are reported below by success or non-success on the NCLEX (Table 1).
The analysis of these data indicates that the nonsuccessful candidates (including the five from the class of 1982) had: significantly lower SAT verbal and math scores, entry science GPAs, cumulative entry GPAs, nursing major test scores, and exit GPAs than their successful classmates. Nonsuccessful candidates also had more academic warnings, and their entry cumulative GPAs drifted downward during the nursing major at a significantly higher rate than the successful candidates.
Correlations were computed, using Pearson's r, all variables with all other variables. Those variables whose correlations were significant at p « .05 were then tested for causal significance using student's t. While SAT scores were significant causal variables, science and prerequisite entry GPAs were found to be stronger predictors of later success on the NCLEX. The graduates' experience in the nursing major as reflected in the senior School of Nursing exams, the actual exit GPA, the number of academic warnings and the difference between the entrance and exit grade point were variables displaying robust causal differences between the successful and the nonsuccessful candidates. Junior exams were not significant since many students who scored poorly during the junior years did not proceed to the senior class.
Opinion, Students: Opinion data about the 1983 graduates' personal characteristics and interaction factors that might have contributed to their nonsuccess on the NCLEX exam were gathered by use of structured interview and questionnaire. All faculty who had taught the 1983 class were interviewed by one of the task force committee members. The interview followed a structured protocol and was analyzed by content analysis.
A sample of 20 students of the 1983 class were also interviewed using the same structured protocol. The sample included five nonsuccessful candidates. Those interviewees, chosen by the use of strict random selection method, were called via telephone and interviewed by one of the students on the task force. All respondents were asked to comment on the characteristics of the class of 1983 and those factors that they felt were associated with the failure rate on the NCLEX examination. The results of the portion of those interviews related to students are displayed in Table 2. Characteristic or associated factors that did not receive a 15% comment rate by either the students or faculty were not included in the matrix reported.
DEMOGRAPHIC CHARACTERISTICS OF UNSUCCESSFUL AND SUCCESSFUL CANDIDATES CLASS OF 1982 AND 1983 COMBINED
In general, all indicators pointed to a bimodal distribution of student ability and characteristic. The faculty saw the students as academically and clinically diverse. The students saw themselves as cohesive and supportive. The faculty thought some students to be passive and immature and others to be agreeable, hardworking, and mature. The students were more apt to indicate lack of essential curriculum content and amount of actual clinical practice as factors associated with the lack of success on the NCLEX. The faculty believed the basic lack of student potential and the lack of match between actual clinical experience and classroom content as the curriculum was unfolded for the learner contributed to the nonsuccess. Faculty felt that once recognizing students with low potential for success, they had inadequate devices for screening them from the program before graduation. Students felt they could have reviewed for the NCLEX exam at a higher rate by participating in a packaged review process. Other factors mentioned less often, and may also have contributed to nonsuccess, were: students' lack of participation in the learning process through studying and attending class, and the teaching method/learner fit along with the quality of some lectures.
FACULTY & STUDENT OPINION OF THE CLASS OF 1983
Faculty Profile: The profile of the faculty teaching students who graduated in 1983 included all faculty teaching those students save one professor who was no longer at the University and was not willing to participate in the interview. The faculty represented all nursing specialty areas, had a Masters level education as a rule (three people had PhDs), with a mean of 9.7 years of teaching and for the most part, the major portion of their teaching experience occurred at the University. Several of the faculty were completing a final year with the School of Nursing during the 1982-83 academic year.
Opinion, Faculty: Opinion data about faculty were also collected by means of the aforementioned structured interview. Teaching was rated by interviewees on a scale of O to 7, O being low and 7 high. A mean score as rated by the faculty was calculated at 5.05, and by the students rating at 4.4, with an overall mean of 4.7. Team teaching as done at the University was also rated on a O to 7 scale by interviewees, O being not useful, and 7 very useful for student learning. A 4.35 mean was tabulated from the faculty and 4.6 from the students' responses, with an overall mean of 4.5. In the area of team teaching, the rate of disfavor and belief that the University employed an incorrect form of team teaching drew a negative response from faculty.
A multi-item questionnaire was circulated to all 1982 and 1983 graduates through the mail to offer a larger number of both graduated classes to participate in the study. Overall, 72 of the possible 176 respondents returned questionnaires anonymously giving a total response rate of 41%.
The respondents generally reported an entry and exit GPA above 3.0. The 1982 respondents had a mean NCLEX score of 2096 and the 1983 respondents, 1940. Eight of the total respondents were non-successful candidates. Three out of four of the 1982 respondents took a state board review and found it helpful, while only one in three of the 1983 respondents had done so. The 1982 respondents had attended class at a higher rate, and carried fewer nonnursing classes during the nursing major. Both groups were predominantly Caucasian, spoke only English, worked one or two days a week at an outside job, and spent 8-15 hours per week in family-related activities. Both groups had enrolled at the University because it was near their homes and had a reputation for excellence.
The 1982 respondents to the questionnaire gave the overall teaching in the Nursing major a mean of 4.0 out of a possible 7 points. The 1983 graduates recorded a mean score of 3.4, with an overall mean between the two classes of 3.6. Thirty-five percent of the people making comments from the class of 1982, 53% from the class of 1983, with an overall of 47% of those making comments about improvement in the University School of Nursing suggested that teaching be improved.
Nearly half of those responding to suggestions for improvement indicated the need for more clinical practice, better skills, labs, and increase in clinical time, while 40% asked for more "back to basics" instructional techniques (Table 3).
Curriculum Conceptual Content: In the last 10 to 15 years there had been a move away from structuring curricula around practice blocks in American Schools of Nursing. Avant-garde curricula have fostered an overall conceptual framework threading concepts across practice areas. The adoption of this integrative form of curriculum has been fostered by the accrediting branch of the National League for Nursing. The University, beginning with the latter half of the 1960s, has participated in this more innovative form of curriculum design. The school was commended in 1980 at the time of its most recent accreditation by the League for its modern design.
The University curriculum was based on an integrated format. That is, conceptual strands that had been identified and threaded throughout the curriculum. The original impetus for the integrated model came from Roy's Theory of Nursing Practice. The vertical strands, called the organizing concepts, were three: protective mechanism, stimulus alterations, and regulatory mechanism. These strands are developed using health potential, simple adaptation problems, and complex adaptation problems as the internal organizers. The three horizontal strands of the curriculum were represented by biopsychosocial adaptation, the nursing process, and the professional role.
GRADUATES' SUGGESTIONS FOR PROGRAM IMPROVEMENT
CLOCK HOURS DEVOTED TO CONTENT AREAS
The curriculum unfolded for students along those horizontal and vertical strands. It did not pivot around the customary style of the areas of nursing practice. Students did, however, have their interactions with the experiential content of the curriculum in the usual practice areas. Due to the style of the integrated model, content being taught in class did not necessarily match the clinical learning situation.
Curriculum Profile: To assess the University nursing curriculum match with the NCLEX content areas, it was necessary to review the six printed packets used by faculty and students that described the curriculum. Two members of the committee reviewed each packet beginning with the first course of the junior year and moving through the final senior course. The number of hours assigned to each of the eight1 NCLEX areas were tabulated. A ninth category, professionalism, was added to accommodate a content area stressed in the University design, but not included in the exam. Since the university did not use either the taxonomy or nomenclature for content assignment as NCLEX does, it was necessary for the curriculum reviewers to make judgments about how the content could best be matched to the NCLEX categories.
It should be noted that areas of locus of decision making in implementing the nursing process were not reviewed in this part of the study. A methodology for such a review was not devised. It was determined that a time-consuming content analysis would be necessary and time was limited for the evaluation project. Table 4 displays the results of the curriculum reviewers efforts. It was difficult to draw conclusions. All exam areas were given attention in the curriculum. The weighting of each area in the exam was unknown. The placement and weighting of those content sections in. the University curriculum provided the impetus for a curriculum review by the School of Nursing curriculum committee. The focus of the review would by necessity include an examination of time given to each content area as well as placement of areas in the curriculum. Inspection of T&ble 4 does indicate a skew in time spent toward the category of professionalism.
To add to the knowledge of content areas appearing in the curriculum, the committee sought to discover University graduates' performance in those areas. The research team was only able to obtain from the testing service such a profile on those students who were not successful; no such data were available for successful candidates. That profile information was tabulated in graphic form and drew attention to the fact that nonsuccessful candidates had deficits in all areas with a clustering of deficit in the area of analyzing, planning, implementing and evaluating nursing care. They also had significant deficits in the areas of human functioning, nutrition, protective functioning, and sensory-perceptual functions. The future computerizing of NCLEX results by successful and nonsuccessful candidates for each school by the testing service would add greatly to the ability to understand this phenomenon.
Opinion: Opinion data about graduates' own strengths and weaknesses were collected via the questionnaires circulated to 1982 and 1983 graduates. Students reported a minimally satisfactory preparation in the use of the nursing process, and felt weakest in the area of implementation of the process. Students commented that they needed more practice in clinical situations. While some of the teaching was good, exams often did not match the content taught and students were not satisfied with their ability to utilize the major curriculum concepts in clinical situations; or when writing research proposals, they were more satisfied with using the curriculum concepts in completing student projects.
Students believed themselves to perform at a lower level than other baccalaureate students in the areas of major curriculum concepts, knowledge, and understanding and applying technical skills (Figure).
Experiential Content - Profile: Assessing students' experience in the clinical areas was done by tracking every student of the 1983 class through their clinical experiences with the exception of the short clinical experience the summer beginning the Junior year. Clinical rotations were grouped by Adult, Child, Maternal-Infant, Mental Health, and Community Health and then in each one of those areas, by instructor. The burden on the faculty during' any particular clinical rotation of eventual nonsuccessful candidates for the overall class varied between O and 5% for most clinical sections. The percentage of burden was slightly higher in the specialty areas. This was possibly due to the limited number of instructors available for those particular clinical areas.
Even though classroom content did not always match the practice focus being emphasized for all students, there was no indication that this was different for the nonsuccessful candidates than the successful. However, the question was raised, given the profile data, about the nonsuccessful students, "Is this integrated manner of unfolding a curriculum the most powerful tool available to assure learning for the entire student group attracted to the University School of Nursing?"
Opinion: The opinion data about both the experiential and conceptual areas of the curriculum were gleaned via the questionnaire and the interviews with faculty and students described earlier. Faculty and students were asked to rate on a O to 7 scale various aspects of the conceptual and experiential learning and then to give opinions about each of those areas. The areas rated lowest by the student and faculty were testing by performance outcome and writing research proposals. Teachers had a higher mean opinion of testing by performance outcome than students. Research content was rated low in comparison to other content areas by both faculty and students. Overall, lectures received a reduced rating by both faculty and students. Student and faculty alike believed that the classroom workload for students was heavy but useful. The faculty had a higher opinion of the value of clinical written work for student learning than did student interviewees. Both agreed that assigned readings and classroom written work was useful for student learning. All respondents reported a high opinion about the overall clinical experiences afforded students of the School of Nursing. Over 50% of the faculty interviewed stated they were unaware of the content areas of the NCLEX curriculum. The graduates interviewed gave a very low rating for the match of the University curriculum with the NCLEX content areas.
GRADUATES' COMPARISON OF SELF WITH OTHER BACCALAUREATE GRADUATES
Overall, comments given to interviewers indicated that students believed they needed more clinical experience, that the skills labs as presently designed did not meet their needs. Some respondents questioned the fit of the current curriculum with the students attracted to the curriculum. The faculty felt that the mechanism of team teaching needed revision.
Discussion and Summary
Exit evaluation of nursing graduates arises out of the desire to protect the consumer through licensing practitioners. The nationwide State Board lest Poo] Examination (SBTPE) began in 1942. By 1950, all states had accepted and used the test pool format. Although nursing practice acts vary from state to state, all currently require the successful completion of this examination for practice. Until 1982, the State Board Test Pool Examination consisted of separate tests in each of the five nursing practice areas of medical nursing, surgical nursing, obstetrical nursing, nursing of children, and psychiatric nursing.
During the meeting of the Council of States Boards of Nursing and the American Nurses' Association in May 1968, it was noted that the Council of States Boards of Nursing should appoint a committee to study of State Board Test Pool Examinations. The work of the committee appointed was research based. The high correlations among the five areas of the test suggested that consideration might be given to adopting a single score pass/fail grade. It was the impetus of this recommendation that underlies the format of the current examination (Johnson, Robery, Kingsbury & Kane, 1979).
The NCLEX examination is now a single score, "integrated" examination. These new eight conceptual categories are the organizing threads of the new "integrated" examination as opposed to the practice areas of the discipline formerly used for state board exams.
The data from the research projects indicate an overall concern about whether the integrated curriculum and teaching methods met the needs of all the learners attracted to the University program as a preparation for the integrated NCLEX. It seemed to prepare the above average learner for the new exam. It was, however, inadequate for the average and below average learner.
The study results suggested that attention be focused for this school in the areas of admission and recruitment of students. The University appeared not to differ on paper in admission standards from other programs in the state save the Health Science University, which admitted only students with a 3-5 college GPA or above. Actual admission acts was not information readily available to the task force. However, many admission committees with large pools of potential applicants are known to deviate by rising significantly above printed standards as they admit students. These schools take very few risks of nonsuccess on exit exams at the time of admission to the program.
The occupation of nursing as it moves to full professionalism struggles with the problem of identifying the parameters of practice. The question of who should be selected to learn the art and science of nursing rests on the answer to the question about practice. Currently, schools of nursing are forced to deal with the question of selection first. It is not known which graduates work longest or successfully in nursing - the average or the brilliant. Many of the brightest of potential candidates are now choosing careers in business and engineering over nursing . As the number of available superior students diminishes, state supported institutions with the lowest tuitions are able to skim the pool leaving B and C students for the privat», more expensive programs. The profession must consider the question about who should learn as an open one until the dimensions of practice are defined. The dilemma for the University School of Nursing and other private, liberal arts programs centers around maintaining a reputation of excellence and satisfying accrediting and licensing agencies while this question about who should be educated is answered. In the meantime avant-garde curricula may be contraindicated for the average learner.
- Hayes, E.R. (1981). Prediction of academic success in a baccalaureate nursing education program. Journal of Nursing Education, 20(G), 4-8.
- Johnson, W, Robery, M., Kingsbury, C., & Kane, J. (1979). Examining the validity of the state board test pool examination for registered nurse licensure. Kansas City: American Nurses' Association.
- Knopke, H.J. (1979). Predicting student attrition in a baccalaureate curriculum. Nursing Research, 28(4), 224-227.
- Maloney, M. (1978). The integrated baccalaureate curriculum: An opinion survey. Nursing Outlook,26, (6), 375-379.
- Outtz, J.H. (1979). Predicting the success on state board examination for blacks. Journal of Nursing Education, 18(9), 35-40.
- Perez, T.L. (1977). Investigation of academic moderator variables to predict success on state board of nursing examinations in a baccalaureate nursing program. Journal of Nursing Education, 16(8), 16-23.
- Seither, F.F. (1980). Prediction of achievement in baccalaureate nursing education. Journal of Nursing Education, 19(3), 28-36.
- Styles, M. (1976). In the name of integration. Nursing Outlook, 24, (12), 738-744.
- Torres, G. (1974). Education trends and the integrated approach in nursing. In Faculty-curriculum development, part IV: Unifying the curriculum - the integrated approach New York: National League for Nursing.
- Veith, S. (1978). Re-thinking the integrated curriculum. Nursing Outlook, 26, (3), 187-190.
DEMOGRAPHIC CHARACTERISTICS OF UNSUCCESSFUL AND SUCCESSFUL CANDIDATES CLASS OF 1982 AND 1983 COMBINED
FACULTY & STUDENT OPINION OF THE CLASS OF 1983
GRADUATES' SUGGESTIONS FOR PROGRAM IMPROVEMENT
CLOCK HOURS DEVOTED TO CONTENT AREAS