The quality of an undergraduate nursing program is assessed using multiple indicators. The accreditation standards from the National League for Nursing Accreditation Commission (2008) and the Commission on Collegiate Nursing Education (2008) attest to this. Despite this, the one indicator—among all others—that draws the most attention is first-time National Council Licensure Examination–Registered Nurse® (NCLEX-RN) pass rates. First-time NCLEX-RN pass rates have long acted as the gold standard signifying nursing program quality. Given the call for change in what, how, and who we teach, nursing education leaders are long overdue in critically challenging this emphasis by analyzing the negative effects this assumption has had, not only on nursing education, but also on the profession.
Evidence from educational research has fueled the push for innovations in teaching and curriculum design. Unfortunately, such efforts are hampered by concerns that curriculum reform and substantive change in teaching practice could result in a drop in first-time NCLEX-RN pass rates. Faculty universally recognize that educational preparation of nursing students should extend well beyond the baseline knowledge needed for NCLEX-RN success, as evidenced by the broad program outcomes found among accredited nursing schools. Regardless, NCLEX-RN success remains a dominant force influencing curricular and educational decisions.
This issue also extends to evaluation. Despite the evidence regarding diverse ways of learning, multiple-choice questions remain the primary method used to evaluate nursing competence in nursing programs and on the NCLEX-RN. Multiple-choice examinations favor individuals with strengths and preferences in low-context applications over those with strengths and preferences in high-context applications; thus, this form of evaluation is not necessarily reflective of an individual’s competence. Alternative evaluation strategies should be explored (Chinn, 2004), with an emphasis on scholarship in this area (Tanner, 2004). However, faculty generally feel compelled to align with the NCLEX-RN as the standard to evaluate students in didactic courses.
The high stakes associated with NCLEX-RN success has financial implications for nursing programs and students. The ability to qualify for and receive state funding, grants, and private donations is affected by reported first-time pass rates. There is also a financial burden associated with NCLEX-RN assessment examinations and remediation. Although available for years, nursing programs have recently begun to rely on extensive assessment and remediation packages offered by commercial vendors to ensure NCLEX-RN success. This trend may lead to false assumptions regarding what students learn as a result of a traditional nursing curriculum. To what extent this artificially inflates the NCLEX-RN passing standard should be considered. Are students who graduate from programs that do not offer such packages at a disadvantage? These assessment and remediation packages, which represent a significant expense to nursing programs and students, are purported to benefit students; however, one must question who is really benefiting—vendors or students?
Concerns regarding first-time NCLEX pass rates have also led to questionable progression policies. Many nursing schools have adopted progression policies based on student performance on standardized examinations that assess preparedness for the NCLEX-RN (Spurlock, 2006). In addition, students who perform well in clinical settings but have low scores on classroom examinations are often prevented from progressing because it is assumed that they lack adequate knowledge. Is this always the case, or is it that we lack adequate methods to assess their knowledge? It would be interesting to know how often such decisions are based on the perceived ability of the student to be successful on the NCLEX-RN after graduation. Policies such as these essentially prevent “at-risk” students from progressing within the program or graduating to ensure that the program’s first-time NCLEX-RN pass rates remain at or above acceptable levels. Such policies are potentially unfair to students and border on unethical educational practice.
These points become even more important when the changing landscape of learners is considered. The unquestionable need for greater diversity within the nursing profession has led to increased admissions of underrepresented minority nursing students. As a group, underrepresented minority students have diverse learning strengths, preferences, and perspectives that differ from the Eurocentric perspective (Hassouneh, 2008). Many underrepresented minority students face challenges related to multiple-choice testing because of contextual, linguistic, and cultural differences (Ibarra, 2001; Lujan, 2008), raising concerns about the cultural biasness of the NCLEX-RN. The emphasis on first-time NCLEX-RN pass rates potentially serves as a disincentive to nursing programs actively working to increase workforce diversity.
The importance of first-time NCLEX-RN pass rates represents a complex issue with far-reaching effects. It is clear that professional nursing competence must be ensured prior to licensure, but the current thinking about this process has not kept pace with changes within education and the profession. Several things can be done to address this:
- Nursing leaders should step up discussions with the National Council about new mechanisms to validate entry-level competence. Because validating competence is not unique to nursing, conversations with leaders from other health education disciplines would be helpful. We must also investigate whether the recent use of outside commercial vendors to ensure NCLEX-RN success has skewed what is considered entry-level knowledge gained as a result of nursing education curricula.
- Nursing faculty, nursing leaders, and accrediting agencies should think about reporting both first-attempt and second-attempt pass rates and treating these equitably. Past resistance to doing so has stemmed from the argument that NCLEX-RN success should be reflective of the nursing program as opposed to postgraduation remediation. The increasingly common practice of outsourcing content remediation to commercial vendors prior to graduation nullifies this argument. Given the multiple issues raised, how can the sole emphasis on first-time pass rates be justified? After all, graduates who eventually pass the NCLEX-RN on subsequent attempts still contribute to the nursing workforce.
- Graduation data, such as persistence to graduation and demographic data of graduates should be reported with the same level of importance as first-time NCLEX-RN pass rates. Is there really anything to celebrate when a nursing program with only a 50% persistence to graduation rate boasts of a 100% first-time NCLEX-RN pass rate?
- Nursing school administrators should talk with their local State Boards of Nursing and state Higher Education Departments about the negative effects the emphasis on first-time pass rates have had on their nursing programs and the resulting consequences on programs when first-time pass rates fall below average.
Until it is resolved, the current emphasis on first-time NCLEX-RN pass rates as a quality indicator of nursing programs will curtail efforts related to innovative learning, evaluation measures, and workforce diversity. Although the long-term impact of this issue is unclear, it is reasonable to question whether professional sustainability is at risk. The alarming number of nurses who leave professional nursing practice within a few years after graduation could possibly be attributed to a de-emphasis on learning in favor of outdated educational models to ensure pass rates on an out-of-date evaluation mechanism. In the end, the entire nursing profession suffers. It is obvious that these complex questions have no easy answers. However, what is clear is our need to reflect on current trends and be willing to reconsider the meaning of NCLEX-RN pass rates. Let the discussions begin!
Jean Foret Giddens, PhD, RN
Professor and Interim Senior Associate Dean of Academic Affairs
College of Nursing
University of New Mexico
Albuquerque, New Mexico
- Chinn, P2004. A praxis for grading. Annual Review of Nursing Education, 2, 89–109.
- Commission on Collegiate Nursing Education. 2008. Standards for accreditation of baccalaureate and graduate nursing programs. Retrieved October 2, 2008, from http://www.aacn.nche.edu/accreditation/pdf/standards.pdf
- Hassouneh, D2008. Reframing the diversity question: Challenging Eurocentric power hierarchies in nursing education. Journal of Nursing Education, 47, 291–292. doi:10.3928/01484834-20080701-03 [CrossRef]
- Ibarra, R. 2001. Beyond affirmative action: Reframing the context of higher education Madison: University of Wisconsin Press.
- Lujan, J2008. Linguistic and cultural adaptation needs of Mexican American nursing students related to multiple choice tests. Journal of Nursing Education, 47, 327–330. doi:10.3928/01484834-20080701-07 [CrossRef]
- National League for Nursing Accreditation Commission. 2008. NLNAC 2008 standards and criteria. Baccalaureate degree programs in nursing. Retrieved October 2, 2008, from http://www.nlnac.org/manuals/SC2008_BACCALAUREATE.htm
- Spurlock, D2006. Do no harm: Progression policies and high-stakes testing in nursing education. Journal of Nursing Education, 45, 297–302.
- Tanner, CA2004. Practical issues in measurement and evaluation. Journal of Nursing Education, 43, 435.