Nursing education programs have suffered from a chronic illness for decades. The disorder causes disruption in the educational environment, in effective assessment, and in the treatment of students. We know more about the cause of this disorder than we do about the most effective treatment for it. Our treatments have been aimed primarily at the symptoms, with little progress on addressing the underlying etiology. In the past 10 to 15 years, we have administered strong, sometimes lethal interventions, but the problem persists. Some might wonder whether we will ever find a cure.
The disorder that plagues us is low NCLEX-RN® pass rates. The most common treatment is the use of high-stakes testing and progression policies, which address only the symptoms of the disorder. High-stakes testing seeks to inflate licensure pass rates by allowing only those students who have little or no chance of failing the licensing examination to take it. This treatment has often been professionally and personally devastating to some students. In their e-mails, phone calls, and personal messages to me, to other nursing education researchers and leaders, and across the Internet, their stories get told. Usually, they are good students—the kind who get A’s and B’s, are inducted into honor societies, and get accepted into graduate school, only to find out that because they did not achieve the required cut-score on a standardized predictive test, they will not be graduating. They will not be sitting for their licensing examination. They will not enter the profession right now—and maybe they never will. One student (of about 30 affected at her school) told me, “I feel as if I have been tricked, that this is a nightmare. Maybe I will wake up from this eventually.”
Although I did not know the topic would define my early research career, for the better part of a decade I have studied the use of high-stakes tests and progression policies in nursing education. My interest in this topic grew, like it often happens, from a local issue that affected me as a faculty member. Through my research, writing, consulting, and exploration of the literature, it is clear that progression policies and high-stakes testing emerged as a solution to a problem—that schools often struggle to maintain NCLEX pass rates at levels acceptable to their state boards of nursing, accreditors, and the public. Without these external pressures, there would be little need for high-stakes tests. This suggestion finds support in the schools that maintain high NCLEX pass rates, but without the use of high-stakes tests. After all, nursing program quality is so much more than what is measured by licensure examination or predictive test pass rates, isn’t it?
Progression policies that rely on standardized tests are often implemented hastily and without enough study, planning, or communication. Faculty may feel relief in having “addressed” their licensure pass rate problem, although they have essentially outsourced significant responsibility for assessment to for-profit companies. Examinations are chosen and cut-scores are set, mostly under the advice of these companies. Faculty often do not have the skills to thoroughly evaluate the psychometric properties of a test, to empirically choose a cut-score that considers the consequences of such choices, and to develop an evaluation plan by which results will be monitored and reassessed. Left unexamined are the essential components of the educational process that result in student learning but over which the student has no control. In sum, progression policies, along with high-stakes tests, are entirely student focused. Where are the reports that implicate poorly provided clinical or classroom teaching? Do we know the effects of faculty turnover on student learning outcomes? What about the teaching provided by novice educators—is it comparable to that of experienced faculty? These reports can rarely be found. We have a one-sided evidence base (one focused on students) that has not moved us toward resolution. Rather than suggest we study the ways we miss in our teaching, I’ll point to another way. (Also worth mentioning here is that students are generally well prepared for the licensing examination. It is how tests that are not accurate in their predictions are used that is most problematic.)
I began this editorial with a disease-education metaphor. That metaphor is apt because it accurately reflects much of the problem-focused research that characterizes nursing education research. What if we applied a different model, perhaps one based on wellness and educational strengths, rather than one based on illness? In searching for best practices on NCLEX success, I find myself asking, “What are the characteristics and practices of nursing education programs that maintain high NCLEX pass rates without the need for high-stakes tests and progression policies?” These programs are effectively educating students without resorting to high-stakes testing schemas, so we need to learn how this is done and what strategies should be more widely used. This type of strengths-based inquiry runs counter to the deficit-centric model most of us are used to, but it has found great success in education (see, for example, Bain, 2004), in psychology (Seligman, 2011), and even in nursing (Moody, Horton-Deutsch, & Pesut, 2007). A framework of positive inquiry in nursing education could be applied to a variety of other scenarios, as demonstrated in the following examples:
- School A makes extensive use of simulation technology to compensate for a lack of available clinical settings, and produces graduates who are as clinically adept as students educated using more traditional clinical teaching models. What structures and practices make School A effective? What techniques do faculty at School A use that yield such positive results?
- Professor B does not lecture when teaching pharmacology to basic nursing students, yet the program’s graduates score higher on their pre-employment medication examinations and are deemed more competent in pharmacology as new nurses than are graduates from other schools. What techniques does this faculty member use that work so well? Do these techniques exist in the literature, and can they be replicated?
These are just two examples of what I will term “positive nursing education research.” My call to readers of the Journal of Nursing Education is to develop a program of positive nursing education research. Nursing education needs this type of inquiry to document what works in nursing education, why it works, and how it might be more widely used. This will require a sustained and rigorous focus on factors that promote resilience, foster innovation and creativity, and enable effective practices within the nursing education enterprise. Readers who know me may expect it of me, but I think identifying what makes for high licensure pass rates is as good a place as any to start.
Darrell Spurlock, Jr., PhD, RN, NEA-BC
Mount Carmel College of Nursing
- Bain, K. (2004). What the best college teachers do. Boston, MA: Harvard University Press.
- Moody, R.C., Horton-Deutsch, S. & Pesut, D.J. (2007). Appreciative inquiry for leading in complex systems: Supporting the transformation of academic nursing culture. The Journal of Nursing Education, 46, 319–324.
- Seligman, M.E.P. (2011). Flourish: A visionary new understanding of happiness and well-being. New York, NY: Free Press.