As students complete their nursing studies they look forward to graduation with excitement. However, many experience some anxiety about the RN-Licensure exam they are required to pass. Passing this exam gives the students feelings of accomplishment and goal achievement. Not passing the exam gives most students feelings of inadequacy and bewilderment about what to do.
Every year graduate nurses fail to pass the NCLEX-RN licensing examination and are immediately denied the opportunity to practice as a registered and even graduate nurse. For some this comes after 2, 3, 4, 5, and even 6 years of study in a school of nursing. In 1992-1993 the national percentage passing rate on this exam was 92.3%. In other words, 7.7% did not pass.
Graduates not passing on the first try are devastated. Most experience grief including phases of denial, bargaining, anger, depression and finally acceptance. Some remain in anger and refuse to try to pass again. Others come to nursing faculty for help. Others will respond if sought out. These graduates need to realize that being unsuccessful at the licensure exam can be viewed as a learning experience.
Faculty and deans of the nursing program also are disappointed and wonder if anything else could have been done to ensure passing. Many schools administer pre-NCLEX tests which give faculty and students a prediction of how good their chances are of passing. Unfortunately, these scores do not always accurately predict how well students will do on the NCLEX.
As well as being concerned for the students who do not pass, faculty are concerned with the reputation and endurance of their nursing program. In some states class means below the national norm require faculty to present a remedial plan to the state board of nursing. An ongoing low norm could jeopardize the school's State Board accreditation, thus, nursing program faculty take the scores very seriously.
Faculty usually formally or informally sit down together to discuss what can be done to improve the scores the next year. Faculty also discuss how the students who have not passed can be supported to enable them to pass on the second try. Both a corrective action on the program and a plan for the graduates who are unsuccessful are needed.
Factors Related to Passing the NCLEX-RN Exam
While a large number of comparative studies have been done to try to find an accurate predictor of success, few have proved reliable over time. For example, scores in the liberal arts courses, scores on the ACT/SAT pre-college entrance examination, NLN tests in each specialty area, the Comprehensive NLN, GPA before entering the nursing program, GPA during the program and grades obtained in each nursing course have been correlated with passing the NCLEX. There would appear to be a correlation with passing when both conceptual and experiential areas of the curriculum are considered as well as student academic potential and performance. No one factor alone can accurately predict individual passing.
Whitley and Chadwick (1986) report one of the first studies of the causes of success for the new board exam on 176 graduates; 28 were non-successful and 148 were successful at the completion of a baccalaureate program. Results indicated that graduates who entered the program with low SAT scores, low cumulative and Science GPAs, who scored below the mean on school of nursing and whose cumulative grade point average drifted downward while in the school of nursing were at a significantly risk of failure.
In a later study by Dell (1987) a variety of factors was also correlated with the NCLEX-RN for 78 senior from three baccalaureate schools. The GPA contributed most to the explanation of variance in the NCLEX-RN. did not contribute significantly to explanation. Dell concluded that non-cognitive factors contributed little to explanations of score variance.
Schiffman (1988) compared NCLEX scores with selected and academia predictors. This appeared to validate the findings Whitley and Chadwick that multiple tors prior to entry into school as well achievement in the program studies determinants of performance. The cant predictors in this study were SAT-verbal scores, and three nursing gram variables; GPAs at the courses second semester sophomore first semester junior year and semester junior year.
Poorman (1988) completed a study 102 students from two universities. Academic aptitude as measured by Cognitive Assessment Tool (CAT) positively correlated with the pass on the NCLEX. Self-perceived grades and self-predicted NCLEX were the best predictors passing NCLEX. A Chi-square test indicated students who passed the NCLEX more likely to believe they were test-takers and reported more thoughts during exams than did who failed the NCLEX. Content yielded a trend toward self-talk cognitions in subjects passed the NCLEX.
In another study with baccalaureate graduates positive correlations were found with cumulative GPA, Mosby Assess Test, pre-entrance test scores, prenursing theory and clinical GPA and NCLEX-RN performance. McKinney, Small, O'Dell and Coonrod (1988) concluded that nurse educators can identify students early in the program whose academic patterns suggest potential difficulty within the nursing major and likely failure on the NCLEX. They suggest that educators introduce curricular, organization, structural and instructional strategies to assist these students throughout their educational experience.
Lengacher and Keller (1990) identified academic predictors of success on the NCLEX-RN examination for Associate Degree Nursing students. The best predictors for performance were exit GPA (R=71), ACT composite scores (R=. 75), and the two nursing theory courses in the second year of the program (R=. 71) and (R=. 79). The best predictor for performance on the NCLEX-RN of the National League for Nursing Examinations were the Basics Two Examination (R=.66) and the Psychiatric Nursing Examination (R=. 70). The NLN Basics One Examination had no predictive value.
In another study of Associate Degree Program students and passing the NCLEX-RN positive relationships were found with all of the seven ASN nursing courses in the program and with SAT verbal scores. Not significant were age at graduation from the program, high school class rank percentile, and SAT math scores (Woodham & Taube, 1986).
The problem of graduating students who do not pass the examination is compounded by the problem of attrition in nursing schools. Nursing student attrition rates vary, for example, associate degree (44%), diploma nursing programs (26%) and baccalaureate degree (41%). With spaces in nursing school limited, the need to tell in advance who will be successful on the NCLEX exam, is important in order to avoid turning potentially successful applicants away (Oliver, 1985). Unfortunately, totally reliable predictors of success in school and on the NCLEXRN are not available and faculty must use their own evaluation of the program and the student in an attempt to take correct measures both with the overall school program and with the student who does not pass.
Techniques to Prevent Failure
In each program's systematic plan of evaluation (a requirement for NLN accreditation), nursing faculty evaluate the state board scores and take appropriate actions to improve the scores in the future. A variety of strategies have been attempted including classes on state board anxiety (Lagerquist, 1992; Rouse, 1987), changing entrance requirements, polishing up test-taking skills, (Lagerquist, 1990), having a required review course at the end of the program, helping graduates to select a review course that will help them (Burckhardt, 1992), encouraging students to have a study plan and use the principles of time management to develop a study schedule and to stick to it (Blanchfield & Lederman, 1991; Mansell, 1991). Students need to be encouraged to select an appropriate study method that meets their individual needs. However, while specific factors like these have not been statistically proven to increase the program's mean pass rate, it is important for faulty to take action based on an assessment of the student.
Strategies to Assist Graduates to Cope with Failure
Graduates who do not pass the NCLEX exam generally feel not only grief but embarrassment. Such graduates usually do not initiate calling faculty members or the nursing dean of the school where they graduated because of this embarrassment. However, the following strategies can be helpful in getting the students to rally for a second try.
An Empowering Interview- After the State Board report arrives at the school and the graduates receive their report, each graduate who failed should be contacted and an appointment set to review strategies for success on the second try. This call is usually received very eagerly by the graduate. During the interview the graduate and faculty member or dean should review the student's grades in the program, scores on predictive tests, and study habits before the board exam. This discussion should be supportive and motivate the graduate concerning likelihood of passing the next time if corrective actions are taken. Offering the graduate support and availability can be very reassuring and can help graduates to start studying for taking the exam again.
The faculty member or dean conducting this interview can also reassure the student that graduates can pass the second time. Referring the student to an article with a personal story of changing failure to success may be useful (Rouse, 1987).
It is also important to discuss with the graduate the need to practice good selfcare techniques. Many persons who do not pass the NCLEX have been in a period of stress before the examination and if they are still stressed, study will be of little value (Blanchfield & Lederman, 1991). Having a positive mind frame can facilitate success (Lagerquist, 1992).
Planning New Strategies to Prepare for the Next Test- Many graduates are not aware of the opportunities available for studying and reviewing for the boards, for example, cassette tapes, review books, reviews on cassette computer discs, the Kaplin state board review course, and review courses.
Obtaining a tutor who will guide the study plan is also a very helpful technique. Some graduates need lessons on how to study. Others need help with taking multiple choice test questions. Some need a private place to study instead of trying to accomplish this while watching children (Blanchfield & Lederman, 1991). Some graduates need counseling for test anxiety and overwhelming stress. A few sessions with a trained counselor may be the key to success. It may be helpful to talk to the graduate about getting family support to allow adequate time to study.
If possible, it is very valuable for the graduate to work as a "float" in a hospital setting rather than staying in the same position on one unit. A plan to rotate through a variety of floors and specialty areas can solidify the student's clinical knowledge, decision-making and knowledge base in nursing.
Offer Ongoing Support- It is helpful that the key person involved in the supportive interview keep in contact with the graduate to verify that the plan is being carried out. This special attention increases the graduate's feeling of worth and could be the boost needed to keep the graduate studying.
Not passing the NCLEX is traumatic for both the graduate and the nursing program's faculty and dean. The faculty need to look at the program and make some strengthening changes such as higher admission requirements, more time in some clinical course, or increased use of NLN tests for specialty areas. Additionally, a supportive faculty member needs to assist the graduate who has not passed to make an individualized plan for succeeding the second time. A variety of ways to assist the graduate in studying, that have been found useful at the author's school of nursing, have been suggested.
- Blanchfield, K. & Lederman, C. (1991, May). Studying for success on the licensure examination. Healthcare Trends and Transition, 2, 38-39.
- Burckhardt, J. (1992, Fall). NCLEX preparation. Graduating Nurse, 32-34.
- Dell, M. (1987). Bivariant and multivariate relationships among certain cognitive and noncognitive factors in explaining differences in scores on the NCLEX-RN made by new baccalaureate nurse graduates. Dissertation at Auburn University.
- Lagerquist, S. (1990, Nov/Dec). Get lucky. Healthcare Trends and Transition, 2(1), 56-57.
- Lagerquist, S. (1992, Spring). The NCLEX game plan. Graduating Nurse, 9-11.
- Lengacher, C, & Keller, R. (1990). Academic predictors of success on the NCLEX-RN examination for Associate Degree Nursing students. Journal of Nursing Education, 29, 163-169.
- Mansell, C. (1991, April). Ready for the NCLEX? Healthcare Trends and Transition, 2, 43-44.
- McKinney, J., Small, S., O1DeIl, N., & Coonrod, B. (1988). Identification of predictors of success for the NCLEX and students at risk for NCLEX failure in a baccalaureate nursing program. Journal of Nursing Education, 4, 55-59.
- Oliver, D. (1985, May). The relationship of selected admission criteria to the academic success of associate degree nursing students. Journal of Nursing Education, 24(5), 197-206.
- Poorman, S. (1988). Levels of test anxiety and cognitions of second semester senior level baccalaureate nursing students preparing for licensure exam. Dissertation at the University of Pittsburgh.
- Rouse, D. (1987). Are you ready for state boards. Nursing, 87(1), 70.
- Schinman, R. (1988). Predictors of performance on NCLEX-RN for baccalaureate nursing school graduates. Dissertation at the University of Connecticut.
- Whitley, M., & Chadwick, P. (1986, March). Baccalaureate education and NCLEX: The causes of success. Journal of Nursing Education, 25(3), 94-101.
- Woodham, R., & Taube, K. (1986, March). Relationship of nursing program predictors and success on the NCLEX-RN examination for licensure in a selected associate degree program. Journal of Nursing Education, 25(3), 112-117.