Journal of Nursing Education

RESEARCH BRIEFS 

Enhancing NCLEX-RN Performance: Assessing a Three-Pronged Intervention Approach

Henry T Frierson, Jr, PhD; Beverly Malone, PhD, RN, FAAN; Patricia Shelton, MSN, RN

Abstract

Student performance on the NCLEXRN is a concern at most schools nursing. Ashley and O'Neil (1991) cited three major reasons for this concern: the impact on the health care profession where NCLEX-RN failure delays or thwarts the entry of individuals into nursing, possibility of facing cutbacks if poor NCLEX-RN performance occurs and persists, and the negative emotional and other problems that may occur for students who fail the examination.

Historically, underrepresented minority students have had less success on standardized tests and the NCLEX-RN has been no exception (Overstreet, 1983). The concern over NCLEX-RN performance for both minority and nonminority students has been evident in other studies (Baradell, Durham, Angel, Kaufman, & Lowdermilk, 1990; Boyle, 1986; McKinney, Small, O'Dell, & Coonrod, 1988; Outtz, 1979). Moreover, in a more recent study, Home, O'Sullivan, and Goodman (1991) reported that a combination of race and GPA accounted for 33% of the variance in NCLEX-RN scores. In addition, numerous studies have shown that performance on previous standardized tests predicts performance on future standardized tests. Specifically regarding the NCLEX-RN, Boyle found that American College Test (ACT) scores of minority nursing students accounted for a substantial 57% of the variance in their NCLEX-RN scores as compared with 24% for white students. Given the historically lower performances on the ACT and Scholastic Aptitude Test (SAT), those implications are ominous as related to the NCLEX-RN and other similar licensure or certifying examinations.

For many students, and particularly minority students, test-taking intervention has been associated with positive effects on test performance. This has been observed in studies that examined performances on tests such as the Medical College Admissions Test, the National Board of Medical Examiners Examination, the Medical Technology Registry Examination, and the NCLEX-RN (Frierson, 1984, 1985, 1986, 1987a, 1987b). A major component of the intervention procedures that improved performance on standardized examinations was instruction on effective test-taking. In addition to the testtaking intervention per se, the use of student learning groups has also been quite positively associated with significant benefits for students* test performance. In professions such as nursing, active faculty involvement and participation are additional components that, when added to an intervention program, should provide a tremendous pay-off for the students, particularly in the area of learning and in socialization toward the profession.

Purpose

The purpose of the study was to assess the associated effects of a three-pronged intervention procedure on NCLEX-RN performance for a class of eight AfricanAmerican nursing students at a historically black state-supported university. The threepronged approach consisted of: (1) instructions in effective test-taking, (2) participation in learning teams, and (3) follow-up activities conducted by the faculty to reinforce the first two components. Notably, students in previous classes had also received special attention and intervention aimed at enhancing their NCLEX-RN performance; however, the results were not overly satisfactory to the school.

Methodology

Performance measure

The performance measure was the NCLEX-RN. The standard for passing is 1600 - approximately one standard deviation below the standardized national mean score of 2000. Thus, based on the 1600 minimum standard for passing, the national passing rate can be expected to be approximately 85% per year.

Intervention procedures

At the fifth week of the spring semester, eight senior nursing students began participating in a special intervention program that emphasized instruction related to effective test-taking, the use of learning team methods, and facultybased reinforcement. The objectives of the first two phases were (1) to enhance the students' capacity to accurately demonstrate acquired knowledge on multiple-choice tests and (2) to encourage them to work in learning teams with the purpose of reinforcing and expanding knowledge related to the nursing education curriculum. Phases…

Student performance on the NCLEXRN is a concern at most schools nursing. Ashley and O'Neil (1991) cited three major reasons for this concern: the impact on the health care profession where NCLEX-RN failure delays or thwarts the entry of individuals into nursing, possibility of facing cutbacks if poor NCLEX-RN performance occurs and persists, and the negative emotional and other problems that may occur for students who fail the examination.

Historically, underrepresented minority students have had less success on standardized tests and the NCLEX-RN has been no exception (Overstreet, 1983). The concern over NCLEX-RN performance for both minority and nonminority students has been evident in other studies (Baradell, Durham, Angel, Kaufman, & Lowdermilk, 1990; Boyle, 1986; McKinney, Small, O'Dell, & Coonrod, 1988; Outtz, 1979). Moreover, in a more recent study, Home, O'Sullivan, and Goodman (1991) reported that a combination of race and GPA accounted for 33% of the variance in NCLEX-RN scores. In addition, numerous studies have shown that performance on previous standardized tests predicts performance on future standardized tests. Specifically regarding the NCLEX-RN, Boyle found that American College Test (ACT) scores of minority nursing students accounted for a substantial 57% of the variance in their NCLEX-RN scores as compared with 24% for white students. Given the historically lower performances on the ACT and Scholastic Aptitude Test (SAT), those implications are ominous as related to the NCLEX-RN and other similar licensure or certifying examinations.

For many students, and particularly minority students, test-taking intervention has been associated with positive effects on test performance. This has been observed in studies that examined performances on tests such as the Medical College Admissions Test, the National Board of Medical Examiners Examination, the Medical Technology Registry Examination, and the NCLEX-RN (Frierson, 1984, 1985, 1986, 1987a, 1987b). A major component of the intervention procedures that improved performance on standardized examinations was instruction on effective test-taking. In addition to the testtaking intervention per se, the use of student learning groups has also been quite positively associated with significant benefits for students* test performance. In professions such as nursing, active faculty involvement and participation are additional components that, when added to an intervention program, should provide a tremendous pay-off for the students, particularly in the area of learning and in socialization toward the profession.

Purpose

The purpose of the study was to assess the associated effects of a three-pronged intervention procedure on NCLEX-RN performance for a class of eight AfricanAmerican nursing students at a historically black state-supported university. The threepronged approach consisted of: (1) instructions in effective test-taking, (2) participation in learning teams, and (3) follow-up activities conducted by the faculty to reinforce the first two components. Notably, students in previous classes had also received special attention and intervention aimed at enhancing their NCLEX-RN performance; however, the results were not overly satisfactory to the school.

Methodology

Performance measure

The performance measure was the NCLEX-RN. The standard for passing is 1600 - approximately one standard deviation below the standardized national mean score of 2000. Thus, based on the 1600 minimum standard for passing, the national passing rate can be expected to be approximately 85% per year.

Intervention procedures

At the fifth week of the spring semester, eight senior nursing students began participating in a special intervention program that emphasized instruction related to effective test-taking, the use of learning team methods, and facultybased reinforcement. The objectives of the first two phases were (1) to enhance the students' capacity to accurately demonstrate acquired knowledge on multiple-choice tests and (2) to encourage them to work in learning teams with the purpose of reinforcing and expanding knowledge related to the nursing education curriculum. Phases one and two consisted of six two-hour sessions each week (because of a one-week interim for spring break, the six sessions were conducted over a seven-week period). The third phase was the follow-up to the initial sessions via the faculty's involvement in reinforcing the students' knowledge related to the nursing school curriculum and assisting them in further developing their test-taking effectiveness. This occurred throughout the remainder of the semester.

In the first intervention session, the students discussed concerns about the NCLEX-RN and standardized tests in general. In the first half of the session, the following areas were addressed: the construction of standardized tests, the purpose of norm-referenced measurement procedures, the scoring format of tests such as the NCLEX-RN, the possible effects of appropriate versus inappropriate test-taking practices on test performance, a listing and discussion of factors that adversely affect test performance, and the impact that an individual's attitude - confidence versus a lack thereof - can have on test performance.

Through discussion and the addressing of students* questions, the purpose of this segment was to remove the mystique associated with standardized tests in general and the NCLEX-RN in particular. Ib emphasize the importance of acquiring effective test-taking skills, hypothetical situations were presented to show how the use of these skills can make a substantial difference in individuals' performances.

The second half of the session was devoted to instruction related to effective test-taking. During this segment, students were taught the use of systematic testtaking procedures to reduce the occurrence of unnecessary errors. These procedures focused on the recognition of key words in the stems, the harmful outcomes from misreading item stems and options, and from misinterpreting item stems ("reading too much into the question"); the use of deductive reasoning to select correct options while eliminating incorrect options or distracters mechanically (with pencil marks); and temporarily skipping difficult or time-consuming items. The students were urged to have confidence in their knowledge even when answering difficult items, particularly when they have taken great effort to prepare for the test (again, a focus on attitude). The students were encouraged not to feel intimidated by tests but instead to view tests as a means of displaying the knowledge that they had acquired. They were advised to be less passive, to take a more aggressive and active mental attitude when taking tests. The remaining half of the first session and all of the next session were devoted entirely to test-taking instruction and practice exercises.

For the second session, the first 30 minutes addressed guessing strategies. Students were taught how to seek identifiable cues that may be applied in answering an item when guessing is the only recourse. The remainder of the session was devoted to the use of the practice items whereby the students applied and reinforced the test-taking approaches introduced in the first session. Practice tests were employed in this session and throughout the remaining sessions.

Table

TABLEFive-Year NCLEX Performance for Spring Semester Graduates

TABLE

Five-Year NCLEX Performance for Spring Semester Graduates

The nursing department faculty prepared the practice tests, which contained 25 to 45 items that related to the nursing education curriculum. The items reflected the general content found in baccalaureate nursing education curricula. Hence, the practice tests allowed the students to apply the suggested test-taking techniques on items that were meaningful to them. Of equal importance, the items represented content that the students were studying or had studied, and consequently were supposed to know. This method ensured that the practice tests were meaningful and helped the students to assess their level of knowledge related to specific content.

During the third session, the students formed working groups, which were to eventually become learning teams. The third session thus consisted of teambuilding exercises. The exercises involved the use of practice tests where students were instructed to answer each test item based on consensus methods - the team members had to agree unanimously on the answer to each item. Arriving at the answer by voting and majority rule procedures were discouraged. The consensus method encourages listening, sharing knowledge, and respecting the knowledge of individual team members.

During the initial exercise of the third session, students first took the practice test individually and then met in their teams. They then selected a recorder to record the group's answers to each item. The students discussed each item, reached consensus on the answers, and the recorders transcribed the agreed-upon answers. To add further challenge and a degree of excitement to the sessions, a format was established whereby each team focused on three measures: (1) the team score; (2) the margin of the team's score above the average score of the individual members; and (3) the margin of difference between the team score and that of the highest individual score.

Whenever a team attained a score considerably higher than the highest scoring member and certainly higher than that of the average individual performance, this was acknowledged as a demonstration of effective teamwork. For example, on a 40-item practice test, if a team had an overall score of 35 and the highest individual score was 34, that team's performance would not be considered as effective as another team's with an overall score of 33 but whose highest individual score was only 27. In the latter situation, the group combined their knowledge more effectively to produce a score significantly higher than the group's best individual performer.

In addition to adding challenge and excitement to the sessions, the contests were meant to facilitate a sense of camaraderie and to encourage the team members to work cooperatively by sharing knowledge regarding information associated with the practice test items. The general premise was that in an effective team, the sharing of knowledge by all team members acts to enhance the knowledge of each member.

The three remaining sessions consisted of continued participation in learning team exercises and reinforcement of effective test-taking techniques. Additionally, students were encouraged to work at least once a week with their teams outside the scheduled intervention sessions. The students were advised to continue weekly team meeting and to reinforce their testtaking skills independently through practice tests until the July administration of the NCLEX-RN. The nursing faculty guided this phase of the intervention method and provided follow-up activities.

Results

As shown in the Table, the mean score of the eight students was 1954.25 (SD =198.68). All eight students passed the NCLEX-RN. The students' scores ranged from 1653 to 2151. NCLEX performances over a four-year period are shown in the Table. The four-year passing rate for spring semester graduates preceding 1988 was 65%. The 100% passing rate for the 1988 group was significantly higher (z= 1.97, p<. 025) than the combined passing rate for the 1984-1987 groups.

Discussion

The three-pronged intervention effort was associated with a significantly improved NCLEX-RN passing rate and mean score. This was quite significant because, for that particular year, the NCLEX-RN was a newly administered form and the national failure rate increased to 16.4% over previous years. From 1983 to 1987, the failure rate ranged from 8% to 11% (Washburn & Short, 1992; "State board," 1988). All eight students passed comfortably and their overall passing rate compared quite favorably to the 83.6% national passing rate for first-time test-takers. Notably, registration records showed the academic profiles of the eight students in the class of 1988 were not significantly different from that of the previous classes; yet, their mean NCLEX performance and passing rate, overall, were significantly better as observed in the Table. Even when compared to the class of 1984, with a slightly higher mean NCLEX-RN score, group performance differences become readily apparent when the highest individual score from each group is removed: 2882 versus 2152 for the 1984 and 1988 classes, respectively; for the remaining seven in each class, there is a 90-point difference favoring the 1988 class.

Conclusion

The results further affirm that a greater number of students can benefit when effective intervention procedures are available. In higher educational settings where students must take standardized tests for certification or licensure, it should be common practice to ensure that students are provided assistance, when needed, to become more effective test-takers. Such measures will ensure that students have better opportunities to truly demonstrate their acquired knowledge. Moreover, the involvement and enthusiasm of faculty assures that the intervention methods will be successful.

In addition to faculty involvement in reinforcement efforts, perhaps one of the key critical strategies related to the success of this intervention involved using the group process to reinforce and maximize learning. In some ways this is paradoxical: because nursing education frequently focuses so intensely on the individual, collaborative group skills may be underdeveloped for the nursing graduate. Nursing education's individualistic orientation for learning, achievement, and responsibility does not resonate within many diverse cultures in America, whether referring to African Americans, Hispanics, Asians, or Native Americans. It is suggested that learning group skills be taught to all students early in the curriculum and reaffirmed throughout the students' educational progress, and not relegated only to a period for special NCLEX-RN preparation. More extensive use of collaborative learning groups or teams may affect NCLEX-RN and academic performance for all nursing students and minority nursing students in particular as indicated by the results of this study. Finally, the intervention methods applied at the school where the study was conducted have continued, and the pass rate for first-time NCLEX-RN examination takers since 1988 has been no less than 92%, a rate above the national average.

References

  • Ashley J., & O'Neil, J. (1991). The effectiveness of an intervention to promote successful performance on NCLEX-RN for baccalaureate students at risk for failure. Journal of Nursing Education, 30, 360-366.
  • Baradell, J., Durham, C., Angel, B., Kaufman, J., & Lowdermilk, D. (1990). A comprehensive approach to preparation for NCLEXRN. Journal of Nursing Education, 29, 109113.
  • Boyle, K. (1986). Predicting the success of minority students in a baccalaureate nursing program. Journal of Nursing Education, 25, 186-192.
  • Frierson, H. (1984) Impact of an intervention program on minority medical students' National Board Part I performances. Journal of the National Medical Association, 76, 11851190.
  • Frierson, H. (1985). Cognitive test performance intervention: Effects on an allied health certifying examination. Journal of Allied Health, 14, 223-229.
  • Frierson, H. (1986). Two intervention methods: Effects on groups of predominantly black nursing students' board scores. Journal of Research and Development in Education, 19, 18-23.
  • Frierson, H. (1987a). Combining test-taking intervention with course remediation: Effects on National Board Subtest Performance. Journal of the National Medical Association, 79, 161-165.
  • Frierson, H. (1987b). Academic performance in predominantly black nursing classes: Effects associated with intervention designed for standardized test preparation. Journal of Educational Research and Development, 20, 37-40.
  • Horne, P., O'Sullivan, P., & Goodman, R. (1991). The use of progressive indicators as predictors of NCLEX-RN success and performance of BSN graduates. Journal of Nursing Education, 30, 9-13.
  • McKinney, J., Small, S., O'Dell, N., & Coonrod, B. (1988). Identification of predictors of success for the NCLEX-RN. Journal of Professional Nursing, 2, 326-332.
  • Outtz, J. (1979). Predicting the success on state board examinations for blacks. Journal of Nursing Education, 18,35-41.
  • Overstreet, L. (1983). A study of the efficacy of reinforcement courses for graduate nurses on success in passing the state board test pool examination in Georgia. Journal of Nursing Education, 22, 28-31.
  • State board failure rate shoots up to 16.4F; higher standard, lower 'ability level' blamed. ( 1988). American Journal of Nursing, 88, 1566, 1582.
  • Washbum, J., & Short, L. (1992). The NCLEXRN and nurse educators. Journal of Nursing Education, 31, 171-174.

TABLE

Five-Year NCLEX Performance for Spring Semester Graduates

10.3928/0148-4834-19930501-08

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