Dr. Reinhardt is Assistant Professor, Dr. Keller is Associate Professor and Associate Director for Undergraduate Nursing Programs, Dr. Ochart Summers is Assistant Professor, and Dr. Schultz is Professor, Associate Dean and Director of the School of Nursing, New Mexico State University, College of Health and Social Services, School of Nursing, Las Cruces, New Mexico.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
The authors thank Tenna Roxanne Schumacher, MSN, RN, for her contribution to the literature search. They also thank the School of Nursing faculty for their continued support of at-risk nursing students.
Address correspondence to Anita C. Reinhardt, PhD, RN, Assistant Professor, New Mexico State University, College of Health and Social Services, School of Nursing, PO Box 30001, MSC 3185, Las Cruces, NM 88003-8001; e-mail: firstname.lastname@example.org.
Assessment of student outcomes is an integral part of program evaluation for schools of nursing. One of the major indicators of these outcomes for nursing education programs is student success on the National Council of State Boards of Nursing licensing examination (NCLEX®). The importance of NCLEX-RN pass rates to nursing education programs in the United States cannot be overestimated, as this is a primary measure of program quality for both state regulatory bodies and national nursing education accreditation agencies. Schools of nursing are accountable for acceptable NCLEX-RN pass rates as a condition for ongoing state program approval and national accreditation. At the same time, schools are also accountable for maintaining acceptable attrition and progression rates for nursing students (Giddens, 2009).
In an effort to meet standards for ongoing approval and accreditation, schools of nursing have adopted a variety of strategies meant to promote successful student outcomes related to NCLEX-RN pass rates. One of these strategies is to administer a standardized, nationally normalized exit examination to assess the readiness of graduating students for NCLEX-RN testing. Student progression policies developed to support this type of testing usually call for the administration of this examination at or near the end of the student’s nursing studies program. A student’s unsuccessful completion of an exit examination usually leads to some form of consequence; such consequences vary by the individual institution’s policy. Students’ performance on these examinations provides invaluable feedback to faculty about curriculum, assessment, teaching, and remediation practices when examination performance measures are used as part of a comprehensive plan for program evaluation.
Even when thoughtful, evidence-based policy and procedures are used to support students’ success in the nursing education program and NCLEX-RN examination, some students still will struggle with the rigor of nursing studies. These at-risk students will find themselves falling behind, leading to frustration and loss of confidence in their ability to master academic challenges. This loss of confidence can often compound their difficulties, aggravating an already desperate situation in which the threat of course failure and potential dismissal from the nursing program can affect their sense of psychosocial integrity. In nursing programs where end-of-program exit examinations are administered, the problem becomes even more acute as at-risk students struggle to complete this last requirement. At the very least, end-of-program failures create a dilemma for students and faculty, which can affect student retention and progression while also asking the broader question of how students can successfully pass courses in a structured curriculum but then be found lacking in basic nursing knowledge at the end (Spurlock, 2006).
Poor student performance on the end-of-program exit examination is a flashing indicator for faculty to investigate program components that contribute to student success, including admission requirements and remediation practices. This article describes the response of one baccalaureate nursing program to an unacceptable number of exit examination failures among senior students preparing to graduate. A crisis management approach for this sudden and acute problem was used to assess the situation and develop and implement an intervention, revising program policies to better support student success by using a quality improvement model (Brown & Marshall, 2008).
The baccalaureate nursing program described is offered by a land-grant institution in the southwestern United States. This school offers a full range of nursing education options, including undergraduate and graduate nursing education. The prelicensure Bachelor of Science in Nursing (BSN) program is state approved and nationally accredited by the Commission of Collegiate Nursing Education. The BSN program admits approximately 96 students per year, 48 each semester. The average number of students enrolled and progressing through the BSN program is approximately 200. As part of the school’s comprehensive evaluation plan, student performance on the end-of-program exit examination is monitored, along with NCLEX-RN pass rates, as reported by the state board of nursing.
NCLEX-RN pass rates for our school of nursing in 2003 and 2004 were unsatisfactory, prompting faculty to undertake an extensive curriculum review and revision. Admission and progression policies were updated, resulting in a change in prerequisite coursework, as well as higher admission standards. A standardized entrance examination was adopted as an evaluation tool to be administered to students already accepted to the first semester of nursing studies. The standardized test adopted was the Health Education Systems, Inc. (HESI™) Admission Assessment. In addition, faculty development was enhanced to meet the common administrative challenge of assuring competent and qualified nursing faculty, as required by state approval authorities and national accreditation bodies. As a part of the changes made to the curriculum, the faculty adopted a policy of end-of-program exit examination testing for all graduating seniors in their final semester.
The crafting of this exit examination policy reflected faculty concerns about patient safety and quality care. Exit examinations purport to measure the minimal level of nursing knowledge required to deliver safe and effective nursing care at the entry level of the profession. For that reason, it made little sense to administer this type of examination at the end of a program of study that includes a capstone course with a semi-independent, preceptored clinical experience in the final semester. The potential for sending underprepared students into this type of clinical experience was a primary concern for faculty. The exit examination policy that was adopted called for testing of the students as a part of capstone course requirements and prior to entering the final preceptored clinical experience. The standardized examination selected was the HESI™ Exit Exam.
Students were allowed three attempts to successfully complete the HESI Exit Exam with a satisfactory score. The score selected was the minimum HESI-recommended passing score of 850. If any student was unsuccessful after three attempts, he or she was issued a failing grade for the course. Students could then repeat the course (and exit examination) in the next semester. The BSN program policies also called for dismissal of any student who sustained two failing grades in any nursing course. A repeated failure of the capstone course due to three unsuccessful HESI attempts could potentially constitute that second failure and the student would be dismissed in the last semester of program studies.
After implementation of new curriculum and exit examination testing, student performance improved on both the HESI and the NCLEX-RN outcome measures. However, in the 2008–2009 academic year, the number of course failures due to unsuccessful exit examination performance began to rise from one to four students per semester to as many as 15 to 20 students per semester. The unexpected rise in HESI Exit Exam failures was thought to be linked to an increase in program admissions with more flexible than usual admission criteria, which was instituted to increase enrollment. As a state-sponsored school, the flexible admission criteria was instituted in an effort to address the forecasted acute nursing shortage. As a result, this prompted more faculty evaluation of teaching and assessment practices. It also resulted in more students who were subject to dismissal from the BSN program in their final semester—a program outcome that faculty and administrators were not willing to accept.
Up to this point, remediation for students struggling with the HESI Exit Exam was a faculty responsibility in the final semester. Students were individually counseled and remediated by the faculty responsible for the senior capstone course. In the few years between implementation of an exit examination and the startling rise in HESI Exit Exam failures, only two students failed to satisfactorily complete the exit examination and graduate from the program. Informal remediation was adequate as long as the number of students requiring assistance was low. The sudden rise in exit examination failures was a clear signal that students needed more assistance with this course requirement than was available. In addition, students identified other issues, such as test anxiety and difficulty answering NCLEX-style questions, as barriers to success. Other barriers were individual concerns rather than program deficits, indicating that a remediation program would need to include more than curriculum content review to be successful. This student feedback, along with exit examination data, convinced the faculty to adopt a broader and more formalized approach for providing remediation to support successful student outcomes. The intent was to create an evidence-based remediation strategy, which could also address other identified challenges that students experience while attempting to complete the HESI Exit Exam in their final semester of nursing studies. Students were given the opportunity to describe barriers to their ability to pass the HESI, however, most declined. Those students who did request individual counseling were referred to the appropriate sources.
Crisis Management for At-Risk Students
Crisis management is a series of steps used to intervene and establish order when events and stressors threaten to disrupt an equilibrium state. The threat to homeostasis could be at the individual, group, or community level, but the steps would still apply. According to Elders (2008), the basic steps are (a) assess the individual and the problem, (b) plan the intervention, (c) implement the intervention, (d) resolve the crisis, and (e) develop an anticipatory plan.
Assessing the Individual and the Problem
The first step calls for assessment of both the individual and the problem. In this case, there were 13 students who had multiple failures to satisfactorily complete the HESI Exit Exam near the end of their nursing studies. Some, but not all, of these students were in danger of dismissal from the nursing program. Because these students had passed all their prior coursework, the exact nature of their problems with the exit examination was unclear. However, it was necessary to structure some type of remediation intervention rather than dismiss these students from the program.
Assessment of the problem began with the collection of data related to the demographics of this student group and of each student’s performance on the standardized testing used in the program. After approval from the university’s institutional review board, the data were used as part of the initial and final evaluation of student outcomes. The HESI Admission Assessment was administered to students at the beginning of the program, but not as a requirement for selection in the admissions process. For the exit examination, composite scores for all examination attempts by each student were collected and statistically analyzed. The statistical analysis was used to provide a baseline for remediation activities. The following statistics results were from the data of 13 students who had multiple failures of the HESI Exit Exam.
Seven (54%) students were Hispanic and four (31%) were non-Hispanic Whites. In addition, one student reported being Asian and one student reported being African American. Of the 13 students in this cohort, nine (69%) were self-identified minorities. The mean age ± standard deviation (SD) was 29.5 years (SD = 6.2 years, range = 23 to 41 years). Seven (54%) students were women and 6 (46%) were men. All students had failed the exit examination at least four times.
Students took the HESI Exit Exam a mean 6.0 ± 1.8 times (range = 4 to 9 times attempted). Women tended to have more attempts than men (6.7 ± 1.9 versus 5.2 ± 1.5, respectively; p = 0.13), although there was no statistically significant difference.
The mean composite entrance examination score was 75.0 (SD = 7.9, range = 60.1 to 85.8). Correlation coefficients were conducted to test the relationships among HESI admission scores and HESI exit results. When Spearman’s rho was analyzed, it was found that the admission composite HESI score was negatively correlated with the number of exit examination attempts; (R = −0.15). This meant that the higher the admission composite score, the fewer attempts were needed to pass the exit examination. In this group of students, seven (54%) of the 13 students had composite scores less than 76.
Planning the Intervention
In our case, remediation for these students was necessary, but the nursing program had no formal remediation program in place. Until this time, the practical outcome of informal remediation was that almost all at-risk students were able to overcome their difficulties with the exit examination and successfully complete this requirement, as well as pass the NCLEX-RN after graduation. However, for the situation in the 2008–2009 academic year, the number of students requiring remediation far outstripped the typical 1 to 4 students requiring it in prior semesters and was too large to continue the practice of informal remediation. Faculty determined that a more formalized approach to remediation was needed.
Numerous studies in the nursing education literature reported remediation programs that were developed to assist students with either success on the NCLEX-RN (Ashley & O’Neil, 1991, 1994; Bonis, Taft, & Wendler, 2007; Frith, Sewell, & Clark, 2008; Heroff, 2009; McGann & Thompson, 2008; Mills, Wilson, & Bar, 2001; Morrison, Free, & Newman, 2008; Morton, 2008; Norton et al., 2006; Sifford & McDaniel, 2007) or success with the HESI Exit Exam (Bentley, 2008; English & Gordon, 2004; Lauchner, Newman, & Britt, 2008; Morrison, Adamson, Nibert, & Hsia, 2008; Newman, Britt, & Lauchner, 2008; Nibert & Young, 2008; Nibert, Young, & Adamson, 2008; Nibert, Young, & Britt, 2008). A set of best practices for remediation can be synthesized from this literature (Table 1). Common to all these reports was that a structured approach to remediation was delivered through a faculty-facilitated specialized course. Although a systemic review by Pennington and Spurlock (2010) cited an empirical model of evaluation as the gold standard for the development and evaluation of a remediation course, they also suggested that a process-improvement approach may support curricular development activities. Therein lies the focus of our remediation plan (Pennington & Spurlock, 2010).
Table 1: Literature Review of Best-Practice Techniques Used in Remediation Courses for At-Risk Nursing Students
Also common in these reports was the call to address individualized student needs, and this was most frequently accomplished by asking each student to identify his or her strengths and weaknesses and to then develop his or her own plan of study and remediation. Although content review for specific areas of nursing knowledge was included in most of these programs, it was not the sole focus of remediation activities. Test-taking strategies, measures to alleviate test anxiety and improve self-confidence, and learning to read and answer NCLEX-style questions were also a part of many of these programs. Using best practices as described in the nursing literature, a faculty-facilitated remediation course was established with the aim to assist students with determining their own learning goals, creating individualized remediation plans, and addressing the barriers to success (Table 2).
Table 2: Opportunities for Success Course Using Best Practices Described in the Nursing Literature
Implementing the Intervention
All 13 students enrolled in a remediation course that met once per week for the entire semester. A seasoned faculty member was assigned as the course facilitator. Students reviewed the reported results of their prior exit examination attempts and determined their own specific areas of content weakness. The students were also asked to identify any nonacademic areas of concern, such as test anxiety or difficulty reading and answering NCLEX-style questions.
Remediation activities in this class were meant to address the nonacademic, as well as academic, challenges these students were encountering. To address academic deficiencies, students were asked to review content on their identified area of weakness and to prepare a presentation for classmates and faculty on the topic. Test-taking strategies were reviewed with the class and students completed practice questions in identified student-specific areas of weaknesses to increase their skills in reading and answering test questions.
The effect of NCLEX-RN failure on the self-confidence of graduated nurses is documented elsewhere (Griffiths, Papastrat, Czekanski, & Hagan, 2004); therefore, it is expected that repeated exit examination failures would have some effect on students’ psychosocial integrity. Identifying the psychosocial determinants of exit examination failure was problematic because there is no routine collection of indicators of psychosocial well-being, such as self-esteem, among the nursing students in this program. To obtain a baseline measure, students were asked to complete a short online assessment quiz meant to provide a simple measure of self-esteem. Although no external validity or reliability of the examination was found, the online quiz was inexpensive and convenient for students and produced a snapshot of student self-esteem at the beginning of remediation (PsychTests AIM, 2010).
Statistical analysis of self-esteem scores demonstrated a mean self-esteem score for the cohort group of 75.5 (SD = 13.4). When mean scores were analyzed by gender, men had significantly higher self-esteem scores than women (84.0 ± 12.5 versus 65.2 ± 4.0, respectively; p = 0.01). Spearman rank order correlations demonstrated a significant negative correlation between self-esteem score and the number of exit examination attempts (Spearman’s R = −0.65, p < 0.05). Although no “cut-point” was established, the differences found related to gender are provocative. These data suggest that self-esteem could negatively affect this cohort group, resulting in repeated unsuccessful attempts to pass an exit examination.
The effect of low self-esteem complicates remediation; therefore, the facilitating faculty plays a critical role in the remediation process. This faculty member must be able to provide both mentorship and motivation to students who are likely suffering from a lack of self-esteem and confidence. At the same time, the faculty member must also encourage students to take control of their own learning to meet their identified learning goals. In a situation where each individual represents a unique combination of strengths and needs, a remediation approach has to be tailored to serve the interests of the individual student. In this case, the facilitating faculty used resources on campus and among nursing faculty to assist students with their individualized learning plans. Test-item experts among the nursing faculty were tasked with preparing students to read and analyze NCLEX-style test questions. The facilitating faculty also saw students during scheduled office hours outside of class time to offer additional assistance and support.
Students who identified severe test anxiety as an issue were advised to seek counseling. If a student chooses this option, our university has a student health center that offers psychological counseling and medication management. However, students could also choose to meet with a nursing faculty member who had extensive experience counseling adolescents and young adults. This faculty member used Story-Centered Care (Smith & Liehr, 2003) and the counseling principles of Huber and Backlund (1991) as a theoretical framework for her counseling practice. She used this same framework (Huber & Backlund, 1991) to assist students through brief interventions based on their personal stories of success and nonsuccess. This combined approach requires students’ self-assessment of their routine study and preparation habits and their own identification of the factors that limit their success. From this assessment, a plan is tailored to address the student-identified individual concerns by teaching him or her to recognize the behaviors and circumstances that are contributing to their current unsuccessful efforts and to deliberately choose a different set of behaviors.
Various techniques for changing students’ behaviors were taught and encouraged. For example, testing periods for exit examinations and the NCLEX-RN are measured in hours. Some students have identified that they tend to lose focus over long periods of testing. A common technique used for these students is to teach them to study in small increments of time, punctuated with small breaks. To encourage them to study for multiple small periods of time, students will drop a colored marble in a jar for each 20 minute period of intense study, followed by a short break. The marble functions as a visual reminder of an episode of successful behavior change. This technique works by promoting a study and test-taking strategy that increases focus and concentration within a defined time boundary (Summers, 2002). The students learn testing behavior that can be used to combat mental fatigue and lack of focus in prolonged testing situations.
Resolution of the Crisis
All 13 students enrolled in the remediation course successfully completed the course and also successfully completed the HESI Exit Exam. These students then entered the final preceptored clinical experience and completed it satisfactorily. After graduation, 12 of the 13 students successfully completed the NCLEX-RN on the first attempt. The remediation class has been continued since this episode of high-failure rates and has been opened to all students in any level of the nursing program who either are identified as high-risk for failure or would like the additional assistance and support.
An essential part of anticipatory planning after a crisis is to reflect on changes and summarize the progress made (Elders, 2008). For the crisis of unacceptably high exit examination failures, reflective evaluation of the data collected and the remediation practices adopted provided insight for improving student success throughout the curriculum. The successful results of this remediation program prompted faculty and administration to make permanent changes in admission and progression policies.
Data collected related to composite scores on the entrance examination indicated that students could potentially be at risk for failure, even if they met established admission standards. Further analysis of data on composite scores from all prior admissions was correlated with grades in the beginning semester of nursing studies. This analysis established a minimum required score for this population of students that supports success in beginning coursework and later success with the exit examination (P. Schultz, personal communication, August 9, 2011). Obtaining a satisfactory minimum composite score on the entrance examination is now a prerequisite for admission to the nursing program.
Identifying and remediating at-risk students has been adopted into our school of nursing’s program policy. Students who fail one nursing course are required to enroll in the remediation class. Students who fail the mandatory Dosage and Calculation Examination at the beginning of the semester are asked to enroll in the remediation course, as are students who experience a break in their studies due to withdrawal for personal or health reasons. Remediation practices from the class have spread to other courses as faculty have become more experienced with identifying at-risk students. Often, a student who fails the first test in a class will be assessed for factors such as test anxiety or difficulty with NCLEX-style questions. Based on that assessment, faculty will act promptly to refer the student for counseling or assist the student to obtain necessary support and resources before a subsequent course failure occurs.
This article reports a small number of BSN students who reached the last semester of their program and became unable to progress to completion. These students became mired in a repetitive cycle of failure that reached a crisis point as each individual struggled with his or her own set of challenges that go beyond a lack of nursing knowledge for entry into practice. This analysis suggests that other, more elusive factors play a significant role in students’ success with high-stakes, end-of-program testing. The contribution of low self-esteem to a pattern of repeated failure was instrumental in designing a remediation program, although a repeat self-esteem assessment was not used as an evaluation measure. The self-esteem assessment could be critical to understanding the problem of students who become trapped in a cycle of failure, which affects their self-esteem and progression. For this study group, female students tended to need to take the exit examination more times than male students, and their self-esteem scores were statistically significantly lower than those of the male students. Further, the lower the self-esteem score, the more times the student needed to take the exit examination.
In a crisis management model, the intervention is planned based on adaptive and maladaptive responses of the affected individual or group (Elders, 2008). If the response is maladaptive, such as a self-perpetuating cycle of failure notable for dropping levels of self-esteem, then the intervention has to address the social and cognitive behaviors that are sustaining the maladaptive homeostasis of the individual. In this case, an individualized approach is necessary to include not just a review of content knowledge but also to employ those best practices reported in the nursing literature, including managing test anxiety, addressing low self-esteem, and improving test-taking skills. Additional practices, such as faculty mentoring and development of a supportive learning environment, provide for a comprehensive strategy to improve student outcomes related to successful completion of nursing studies.
Student success is a concern for all nursing schools. Accountability for NCLEX-RN pass rates, along with accountability for student attrition and progression, creates the need for nursing schools to carefully select applicants and then to actively manage their progress. The nursing program described in this article has had high NCLEX-RN pass rates (94% to 96%) in the past few years, along with low student attrition. To encounter multiple students repeatedly failing an exit examination after satisfactorily completing all prior coursework creates concern and distress for faculty and school administration, as well as for students. With a sudden and unexpected increase in student failures, a crisis management approach worked well for this nursing program and helped to resolve an acute problem. In addition, the assessment phase of crisis management created an opportunity to evaluate essential program components (i.e., admissions standards) and to make adjustments that would enhance future student success. In this case, adoption of remediation activities, based on best practices as reported in nursing literature, resulted in successful students and successful program outcomes.
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Literature Review of Best-Practice Techniques Used in Remediation Courses for At-Risk Nursing Students
|Ashley & O’Neil (1991)||Ashley & O’Neil (1994)||Frierson, Malone, & Shelton (1993)||Morrison, Free, & Newman (2008)||Frith, Sewell, & Clark (2008)||Morton (2008)||Sifford & McDaniel (2007)||McGann & Thompson (2008)||Brown & Marshall (2008)|
|Learning teams and discussion group||X||X||X||X|
|Faculty follow-up and mentoring||X||X||X||X||X|
|Individualized plan for improvement||X||X|
|Assessment of strengths and weaknesses||X|
|PowerPoint® presentation and gaming||X||X||X|
|External review course||X||X|
Opportunities for Success Course Using Best Practices Described in the Nursing Literature
|Course-Required Activity Component||Approach|
|Mandatory attendance and signed contract with the Associate Director of Bachelor of Science in Nursing program||Attendance and contract|
|Program dismissal if noncompliant|
|Documented participation in external review program with progress indicators||External review program (HESI 2.0, Kaplan Review, and NLN)|
|Documentation with progress reports given to the instructor weekly|
|Assessment of self-esteem||Online assessment of self-esteem (PsychTests AIM, 2010)|
|Individual coaching for test-taking assessment and focused review techniques||Individual coaching by faculty in test and study techniques|
|Individual counseling to address test anxiety and promote self-efficacy|
|Self-assessment of student content knowledge deficiency in prior HESI™ Exit Exam||Review of all previous HESI Exit Exams and identification of low score areas|
|Student-developed plan for review of deficient content areas||Written review plan approved by instructor|
|PowerPoint® content presentation of area of weakness||Presentation topic approved by instructor|
|Presentation included pretest–posttest and self-evaluation|
|Presentation to class and additional faculty as available|
|Required active participation||Socratic discussions during practice test reviews monitored by faculty|
|Support from all faculty||Content for review examinations obtained from faculty|
|Faculty invited to attend PowerPoint presentations|
|Weekly reminders and encouragement to attend PowerPoint presentations were sent to faculty|