Dr. McDowell is Chair of Nursing, Newberry College, Newberry, South Carolina. At the time this article was written, Dr. McDowell was Professor and Chair of Nursing, Lander University, Greenwood, South Carolina.
This article was developed from the paper “Leadership in Maximizing NCLEX Performance,” presented at the Sigma Theta Tau International Convention, November 2005.
Address correspondence to Betsy M. McDowell, PhD, RN, CCRN, CNE, Chair of Nursing, Newberry College, 2100 College Street, Newberry, SC 29108; e-mail: Betsy. McDowell@newberry.edu.
Performance of graduates on the NCLEX-RN® examination is considered a key indicator of the quality of a nursing education program. Although educators are not supposed to “teach to the test,” nursing faculty repeatedly strive to provide their students and graduates with opportunities to be successful on the licensing examination. Low NCLEX-RN pass rates can negatively affect a nursing program’s recruitment and retention, funding, and approval and accreditation. The purpose of this article is to explore the KATTS framework for optimizing NCLEX-RN performance and how it can be used by nursing education programs or by individuals in preparing for the licensing examination.
Examination and licensure of potential nurse candidates began in the early 1900s with examinations consisting of 50 essay questions (Crawford, 2001). Since that time, the licensure examination has evolved so that currently, the NCLEX-RN consists of a computer-adapted test that is individualized for each test taker. The NCLEX-RN consists of between 75 and 265 questions, presented as traditional multiple choice or alternative format questions in a testing period of 6 hours per test taker. The NCLEX-RN test plan is revised every 3 years on the basis of results of job analyses of the practice of new nurse graduates, defined by the National Council of State Boards of Nursing as those situations commonly encountered in the first 6 months of practice (Aucoin & Treas, 2005).
The NCLEX-RN Preparation Process
It is not unusual for nursing students to save focused preparation for the NCLEX-RN examination until near the end of the nursing curriculum or even following graduation. However, just as students are taught that discharge planning begins on the patient’s admission to the hospital, preparation for the NCLEX-RN actually begins with the student’s admission to college and initial nursing courses (McQueen, Shelton, & Zimmerman, 2004). In many nursing education programs, standardized testing begins in the first semester of nursing courses and includes achievement examinations taken at the conclusion of the major content courses in the nursing curriculum (McQueen et al., 2004). Such activities provide a foundation for preparing adequately for the NCLEX-RN.
It is impossible for current nursing curricula to cover all of the knowledge that nurses could possibly need for nursing practice, so the NCLEX-RN targets the knowledge and skills required for minimum safe, effective nursing care. Review books and review courses have been an integral part of preparation for the nursing licensure examination for at least 25 years. In the author’s experience, nursing graduates frequently undertake individual preparation for the NCLEX-RN using the same test preparation methods they used in school—primarily review of notes and textbooks. Preparation for the NCLEX-RN requires different methods because the licensure examination tests students’ use of critical thinking skills and other higher thought processes rather than recollection of information (Frith, Sewell, & Clark, 2005; McQueen et al., 2004).
Traditional NCLEX-RN review courses have emphasized “review of content” rather than the overall process of effective test-taking. Such NCLEX-RN review courses combine extensive content review with practice questions, and frequently include a post-test. Some nursing programs incorporate structured NCLEX-RN preparation courses into their required curricula. There are also several commercial review programs available on the market today, offering live, audiovisual, and Internet-based formats.
Reports in the nursing literature divide the factors associated with NCLEX-RN success into two categories—academic and nonacademic. Academic factors that have been demonstrated in some studies to predict NCLEX-RN success include cumulative grade point average; grades in specific courses such as pathophysiology, medical-surgical nursing, and the last nursing course in the curriculum; performance on standardized subject tests generally completed at the end of specific courses; performance on comprehensive tests such as the Mosby Assess Test and the Health Education Systems, Inc. (HESI) Exit Exam; and completion of a structured review course (Arathuzik & Aber, 1998; Crow, Handley, Morrison, & Shelton, 2004; Frith et al., 2005; Sayles, Shelton, & Powell, 2003; Stark, Feikema, & Wyngarden, 2002; Waterhouse & Beeman, 2003). Nonacademic factors found to influence NCLEX-RN performance include the level of test anxiety, amount of self-esteem, degree of fatigue, presence of role strain, and the level of family and work responsibilities competing for the student’s time and attention (Arathuzik & Aber, 1998; Beeman & Waterhouse, 2003; Crow et al., 2004; Frith et al., 2005; Sayles et al., 2003; Stark et al., 2002; Waterhouse & Beeman, 2003). One study explored test anxiety in nursing students and concluded that strategies that bolster self-confidence and increase student feelings of control are effective in reducing test anxiety (Edelman & Ficorelli, 2005).
Successful NCLEX-RN preparation programs reported in the literature combine strategies addressing several academic and non-academic factors, rather than implementing single interventions such as addition of a review course to the curriculum (Frith et al., 2005; McQueen et al., 2004). Suggestions from successful NCLEX-RN candidates include the need for students to demonstrate self-responsibility in their preparation, persistence, use of a variety of resources, and the practice of self-care (Frith et al., 2005).
The KATTS Framework
In the early 1990s, a test-taking theory was developed to structure the author’s remedial tutoring programs for the NCLEX-RN. This theory ultimately became the Knowledge base, Anxiety control, and Test-Taking Skills (KATTS) framework and has been used over the past 6 years as the basis for NCLEX-RN preparation of first-time test takers at the author’s university. The KATTS framework focuses on three components of achieving a maximum score on an examination—an adequate knowledge base, active anxiety control, and effective test-taking skills. In KATTS, each of the components becomes one side of an equilateral triangle, demonstrating that all three components must be present and in proper balance to maximize scores. If any one component is low, then the score earned on the examination will be lower than what could be achieved. Conversely, by strengthening not just one but all of these three components, students or graduates can improve their overall test scores significantly. The KATTS framework can be used by all students, including those identified as at risk (Ashley & O’Neil, 1991, 1994; McQueen et al., 2004; Stark et al., 2002).
The successful completion of an approved nursing education program provides graduates with an adequate knowledge base for success on the NCLEX-RN. Therefore, NCLEX-RN preparation from a KATTS perspective focuses on comparing the students’ or graduates’ knowledge levels with the current NCLEX-RN test plan, identifying any “holes” in their knowledge base and “plugging those holes” by reviewing the weak content, and then being able to use that knowledge to answer questions.
Suggested activities for strengthening the knowledge base component of KATTS include:
- Developing an individual study plan for the final semester on the basis of a multi-source assessment of personal strengths and weaknesses regarding the current NCLEX-RN test plan. At the author’s school, students develop their individual study plan from results of two comprehensive examinations taken at the end of the first semester of the senior year, results of end-of-course standardized examinations, student performance in individual courses, and personal comfort level with the content.
- Completing content tests based on strengths and weaknesses identified on the student’s individual study plan. This process is facilitated by using computerized banks of test questions that allow the student to preselect question categories from a menu of designated content areas.
- Conducting a focused review of weaknesses identified through question drill rather than through traditional study methods, such as review of notes and textbooks.
- Completing comprehensive NCLEX-RN pre-examinations at a level predictive of NCLEX-RN success (Frith et al., 2005; McQueen et al., 2004).
Active anxiety control is necessary to perform well on any examination. When controlled, a little anxiety is helpful, serving as a motivator that encourages students to take a test seriously and to prepare for it adequately. However, too much anxiety can result in negative consequences. These negative consequences include not using study time productively; misreading questions; changing answers from right to wrong; blanking on questions; and developing physical symptoms such as diarrhea, sweaty palms, and palpitations (Edelman & Ficorelli, 2005). From a KATTS perspective, active anxiety control involves eliminating the fear of the unknown, maintaining a positive attitude and a vision of the goal (such as in the children’s book, The Little Engine That Could), gaining a sense of control over the environment, and being exposed to test situations and conditions like those encountered on the NCLEX-RN.
Suggested activities for strengthening the anxiety control component of KATTS include:
- Maintaining a positive attitude and a vision of the goal. With the NCLEX-RN, the goal is becoming an RN!
- Using guided imagery, meditation, visualization, and other relaxation techniques before and during tests.
- Using stress management strategies with daily activities and with test preparation, resulting in a sense of control over the testing situation.
- Retaining personal wellness through healthy eating, attention to adequate sleep, and inclusion of diversional activities.
- Combining individual review activities with activities in small study groups for social support and increased confidence.
- Completing practice questions and practice examinations on a computer, to increase candidates’ comfort levels with computerized testing.
- Completing a walk-through of the NCLEX-RN process so there are no surprises. Students are encouraged to visit the site the day before the testing appointment and review the route from their hotel or house to the testing center.
- Preparing well in advance of the examination—the entire last semester or the entire senior year—according to one’s individual study plan, rather than trying to cram for the examinations (Edelman & Ficorelli, 2005; Frith et al., 2005; McQueen et al., 2004; Stark et al., 2002; Williams & Bryant, 2001).
Effective test-taking skills can make the difference between passing and failing a test. Students who have been labeled poor testers can become successful test takers by effective use of test-taking skills. As with learning to play a musical instrument or any psychomotor skill, practice is the key to developing effective test-taking skills. Therefore, from a KATTS perspective, practice in answering NCLEX-RN-style questions, understanding the rationales for individual correct and incorrect answers, and using a question drill process provide the best opportunity to develop test-taking skills. Question drills involve answering multiple questions at one sitting (e.g., 50 questions in 1 hour or 100 questions in 2 hours), scoring those questions, and then using the results to identify areas of content for targeted review.
Suggested activities for strengthening the test-taking skills component of KATTS include:
- Scheduling NCLEX-RN preparation time each week, as if it were a course or other recurring appointment.
- Using a question drill to content review ratio of 2:1 or 3:1 or higher, so that 2 hours of question drill are associated with a maximum of 1 hour of content review. (Traditional review strategies use the reverse ratio, with emphasis on content review followed by answering a few questions to demonstrate mastery of the material.)
- Completing targeted content tests and comprehensive NCLEX-RN pre-examinations at a score predictive of NCLEX-RN success.
- Completing a minimum of 2,000 to 2,500 questions involved in the review course or review process. A minimum of 3,000 to 4,000 questions is recommended for at-risk students (McQueen et al., 2004; Stark et al., 2002; Williams & Bryant, 2001.)
The NCLEX-RN pass rate at the author’s school was between 77% in 1998 and 85% in 2000 with the last major curriculum revision implemented in 1998. With the current NCLEX-RN preparation format based on the KATTS framework, the cumulative NCLEX-RN pass rate between 2001 and 2006 at this university has increased to 97%, with only 5 of a total of 143 graduates unsuccessful on their first attempt at the NCLEX-RN in those 6 years. (The pass rate for 2 of those years was 100%.)
Passing the NCLEX-RN on the first attempt enables new graduates to enter the nursing workforce in a timely manner after graduation. Success on the NCLEX-RN infuses these new nurses with a confidence and enthusiasm that influences their nursing care. For many, it is the culmination of a lifetime goal.
Having high NCLEX-RN pass rates is advantageous for academic institutions. At the author’s school, the size of the prenursing class has doubled in recent years, with many new and prospective students (and their parents) noting that the school’s high NCLEX-RN pass rate was an important factor in choosing this school. In spring 2006, a second class of new nursing majors was admitted, a first in the history of this institution. These events illustrate that high NCLEX-RN pass rates can contribute to the effective recruitment of students, an important factor in combating the nursing shortage. Recruitment of faculty also may be influenced by high NCLEX-RN pass rates, since potential faculty members may choose to be associated with a successful program.
High NCLEX-RN pass rates also have the potential to increase institutional and community support for the nursing education program. Potential donors may be more interested in supporting a nursing education program with a high NCLEX-RN pass rate than in assisting a program with lower rates, a source of crucial community support in the face of decreasing state funding and spiraling costs. Finally, high NCLEX-RN pass rates help insure continuing approval by the state board of nursing and accreditation of the nursing program by national groups such as the National League for Nursing Accrediting Commission and the Commission on Collegiate Nursing Education.
As long as successful performance of graduates on the NCLEX-RN examination is an indicator of the quality of a nursing education program, nursing faculty will strive to provide their students and graduates with opportunities for success on the licensing examination. The KATTS framework is an effective method of improving NCLEX-RN performance with benefits for both the nursing education program and the individual nursing graduate.
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