Graduates of nursing programs must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN) to obtain licensure to practice as an RN in the United States. Each year, more than 20,000 nursing school graduates fail the NCLEX-RN (National Council of State Boards of Nursing [NCSBN], 2016). Failure has serious consequences for graduate nurses themselves, nursing programs, and the nursing profession overall (Altemafac, 2014; Mc Farquhar, 2014; Roa, Shipman, Hooten, & Carter, 2011). While the literature on first-attempt failure and how to minimize it is robust, there is a paucity of literature about strategies to support graduate nurses who fail the NCLEX-RN for success on subsequent examination attempts. Over 50% of graduate nurses who fail NCLEX-RN once fail it again (NCSBN, 2016). Successive failures increase graduate nurses' risk of being caught in a downward spiral, and recovery is difficult without assistance (Griffiths, Papastrat, Czekanski, & Hagan, 2004).
The purpose of this article is to describe the implementation of a tutoring-based process for remediating individuals who have failed the NCLEX-RN. This process was developed 25 years ago by one of the authors who has used it consistently with a success rate of over 95%, even with graduate nurses who began the process after multiple NCLEX-RN failures. In recent years, two other faculty have used this method with similar results. Although the method has not been rigorously studied, the authors have repeatedly implemented this educational remediation technique to help graduates successfully pass the NCLEX-RN after initial failure.
Trends in NCLEX-RN Pass Rates
NCLEX-RN pass rates are reported by the NCSBN on an annual basis. From 2006 to 2012, the overall annual average pass rate for first-attempt test takers ranged from 85.5% to 90.3% (NCSBN, 2016). From 2013 to 2016, the annual average pass rate decreased and has ranged from 81.8% to 85.5%. Prior to 2013, nearly half of graduate nurses (45%) who failed on their first attempt were unsuccessful on their second attempt. Since 2013, second-attempt failure rates have increased to between 54% and 56% (NCSBN, 2016). These data clearly demonstrate that graduate nurses who fail NCLEX-RN on their first attempt are at substantial risk of failing again on their second attempt. When a candidate has failed NCLEX-RN once, he or she must overcome significant challenges to pass on the second attempt.
Consequences of Failure on NCLEX-RN
Failure on NCLEX-RN can be a devastating experience. First-attempt (Altemafac, 2014; Roa et al., 2011) and subsequent (Griffiths et al., 2004; Silva, 2014; Woo, Wendt & Weiwei, 2009) failures are associated with emotional and financial strain for the graduate nurse. Academic and nonacademic risk factors for first-attempt failure on the NCLEX-RN have been identified. Academic factors include overall grade point average, science grade point average, and scores on NCLEX-readiness tests. Nonacademic factors include test anxiety, self-esteem, English as a second language, work–family responsibilities, and transfer from another program (Kline, 2010; Poorman, Mastorovich, Liberto, & Gerwick, 2010; Rollant, 2007; Simon, McGinnis, & Krauss, 2013; Woo et al., 2009).
Nursing programs that fail to meet their state boards of nursing benchmarks experience consequences, such as program probation or program closure. For these reasons, nursing programs use first-attempt pass rates as an outcomes indicator, and take measures to prevent failure from occurring. Multiple strategies for preventing first-attempt failure on NCLEX-RN have been described, and policy-based strategies include integrating standardized testing platforms. Such strategies are designed to ensure only students likely to pass NCLEX-RN will graduate. Many nursing programs dedicate resources to developing strong student–teacher relationships so faculty will better meet underachieving students' needs (Poorman et al., 2002).
Many faculty have not had the opportunity to work with graduate nurses who have failed the NCLEX-RN, and relatively little is documented about resources to assist graduate nurses in becoming successful after NCLEX-RN failure. One challenge for these graduate nurses is that schools of nursing may not have resources to dedicate to graduates. Graduate nurses may seek assistance from a vendor where they have taken a review course or buy additional study materials. Descriptions of tutoring using strategies for improving NCLEX-RN success after failure have not been documented in the literature.
Characteristics of Graduate Nurses Who Fail the NCLEX-RN
In tutoring individuals who failed the NCLEX-RN, the authors have found that there are often shared characteristics between clients, particularly in respect to beliefs about the reasons for failure, approaches to studying and test taking, and a dichotomy between perceived and actual strength of their knowledge base. Although this evidence is anecdotal, it is important to have an awareness of these common perceptions to effectively work with clients.
Graduate nurses who have failed the NCLEX-RN typically believe their failure is attributable to test anxiety, poor test-taking skills, and being a hands-on learner. They often report performing better in clinical than in the classroom, even though they believe themselves to have studied more than their classmates. When asked to describe their study techniques, these graduate nurses typically state they recopy notes, reread content, highlight text in assigned materials, and complete questions from practice tests. Although they review questions they answered incorrectly, they do not go beyond a cursory review of the correct answers and rationales. The study strategies reported are often passive strategies and not active strategies that support long-term memory recall (Markant, Ruggeri, Gureckis, & Xu, 2016).
The Tutoring Process
What follows is a description of how to implement a tutoring process developed by Dr. Marian Condon. This tutoring process has been used both for graduate nurses who have experienced a first failure and for others who have experienced multiple failures. When graduate nurses engage in the tutoring, they become a client in the process and will be referred to as such in the description of the tutoring. After 10 years of utilizing this tutoring process, Dr. Condon taught two other faculty and continues to serve as a consultant and advisor as the tutoring process is utilized.
To date, tutoring clients have learned of the service by word of mouth. Because the clients are often in fragile financial states having graduated, often ties with substantial debt and not obtaining employment as an RN, the tutors each offer services based on ability to pay, or contract for payment, following licensure and employment as an RN. The tutoring is not included in the faculty workload; in fact, clients are most often not from the nursing program where the faculty are employed.
The Initial Consultation
The tutoring begins with an initial consultation. Clients often come to the initial consultation displaying signs of the emotional devastation common among graduate nurses who have failed the NCLEX-RN, particularly those who failed more than once. During the initial consultation, a focus is in establishing rapport. The one-to-one tutoring relationship is perceived by the authors to be an important part of the process that contributes to success.
Clients are asked to bring to the initial consultation reports on standardized readiness examinations, results on all NCLEX-RN attempts, and an academic transcript. These pertinent records are reviewed, and this information is used to estimate the degree of remediation required. Because the NCLEX-RN is a computer-adaptive test and questions are administered based on the candidate's response in relation to the passing standard, the examination can range between 75 and 265 questions (National Council of State Boards of Nursing, 2016b). It has been the authors' experience that a client who failed the NCLEX-RN with a relatively low number of questions was performing below the passing standard in several categories and will require substantial remediation. Clients who have failed the NCLEX-RN more than once also require substantial remediation, which includes both content review and test-taking strategy. There is variability in the number of tutoring sessions required because of the differences in amount of remediation required and how much time a client can devote to studying. On average, it takes seven to nine sessions over a period of 3 to 4 months for a given client to develop the knowledge and skills for success on the next NCLEX-RN attempt.
Two core strategies—the nugget method and the six-step approach to question analysis (Condon & March, 2011)—are explained and demonstrated. Clients are also taught how to evaluate and track their progress. When clients are given an overview of these core strategies, they identify the weaknesses in their study approach. Learning new strategies that have been linked to success provide the graduate nurse with encouragement.
The Nugget Method
The nugget method is a core strategy in the tutoring process developed by Dr. Condon (Condon & March, 2011). A nugget is defined as an item of knowledge—a fact or an accurate explanation of a concept. The nugget method involves three processes: (a) clients use NCLEX-RN preparation tests to identify information (nuggets) currently missing from their knowledge base, (b) they formulate questions based on nuggets and enter them into a nugget list, and (c) they repeatedly challenge themselves to answer nugget list questions correctly. The nugget method involves processes known to enhance encoding of information into long-term memory: metacognition (Pintrich, 2002), active recall (Karpicke & Roedinger, 2008), and challenging recall repeatedly (Bahrick & Hall, 2005).
In the nugget method, clients use test questions from online or hard-copy sources (or both) to identify nuggets of basic nursing information currently missing from their knowledge base. They answer sets of questions, check their results, and analyze each question they answered incorrectly. They look up the correct answer and the rationale, and they identify the discrete pieces (nuggets) of information they needed to answer the question but did not possess. They then write each nugget in the form of a question (e.g., What is the normal pH range for arterial blood?) and add it to their nugget list. The nugget list, on which nugget questions are written or typed sequentially down one half of the page with the answers across from them, becomes a steadily increasing repository of information. Clients review their nugget list often to ensure its contents are lodged securely in their memory. They cover the answer column and challenge themselves to answer the questions correctly. A nugget list can be thought of as a centralized, and more easily managed, alternative to flash cards.
The nugget method engages in metacognition (Pintrich, 2002) when clients analyze the questions they answered incorrectly on preparation-test questions, striving to identify information they lacked. Clients engage in active recall (Karpicke & Roedinger, 2008) when they challenge themselves to answer nugget list questions. Clients are instructed to readdress nugget list questions at prescribed intervals, ensuring that recall is challenged repeatedly (Bahrick & Hall, 2005). Tutors present clients with questions from their nugget lists as a way of assessing compliance. The nugget method is an inherently active study technique. It forces clients to test recall and understanding each time they review their list.
The Six-Step Approach to Analyzing Test Questions
The second strategy in the tutoring method developed by Dr. Condon is the six-step approach to analyzing test questions (Condon & March, 2011). The authors' experience has been that individuals, particularly those with more than one failure, approach multiple choice test questions in an ineffective manner. Clients are taught a six-step approach to analyzing test questions that corrects the tendencies outlined above (Table). This approach appears simple, yet mastering it takes time and discipline. Clients are advised to practice it deliberately until using it becomes habitual. Tutors reinforce the use of these methods during tutoring sessions by asking questions from the nugget list or assessing question analysis techniques.
The Six-Step Approach to Analyzing Questions
Subsequent Tutoring Sessions
If the client wishes to pursue individualized tutoring after the initial consultation, a homework assignment is given that prepares the client for the next session. Clients complete a comprehensive practice test using the six-step approach. They review their results and apply the nugget method to questions they answered incorrectly.
With the second session, clients are taught to classify their incorrect responses on the practice test into one of three categories: knowledge error (i.e., did not know the question or answer content), reading error (i.e., misread or misunderstood the question), or analytical error (Condon & March, 2011). They are also taught to begin what will become on ongoing record of the frequency with which they are committing theses errors as a way of tracking progress.
Early in the tutoring process, clients are coached in developing an ongoing NCLEX-RN preparation plan tailored to their lifestyle and the degree of remediation required. Clients' circumstances significantly vary, and some clients may need to devote relatively more time to studying than others. All clients are encouraged to get adequate sleep and utilize stress-management techniques. Between tutoring sessions, clients are expected to complete a certain number, or range, of practice test questions. When assigning practice test questions, tutors must keep in mind that quality yields better results than quantity. It is imperative that clients take the time to apply the six-step approach with each question, mine all nuggets from questions answered incorrectly, write well-crafted nugget questions, and detect reading and analytical errors.
Determining Readiness to Retake the NCLEX-RN
Clients should not retake the NCLEX-RN until they have strengthened their knowledge base sufficiently and learned to analyze test questions effectively. Strong performance (percent scores above, or at least within, the recommended range) on at least three comprehensive practice tests from sources the client has access to or pays for is the best indicator that a client is ready to retest. By the time clients are ready to take the NCLEX-RN again, the confidence gained through the preparation process will likely have mitigated their test anxiety. Even if it has not, test anxiety is best regarded as a side effect, rather than a significant cause, of poor performance on tests (Poorman et al., 2010).
Future Research and Next Steps
Although this tutoring approach has been effective for many graduate nurses who have failed the NCLEX-RN, more research needs to be conducted to determine the effectiveness of the overall approach compared with each of the elements: a one-to-one tutoring relationship, the nugget method, and the six-step approach to analyzing test questions. Most students at high risk for NCLEX-RN failure are identified by faculty early in the education process. Future research needs to focus on the effectiveness of implementing these strategies for high-risk students, and remediation courses could be developed for high-risk students using these methods. The authors also recommend that faculty advocate for resources necessary to remediate students because training and dedication are required to do this work.
Reflections on the Tutoring Process
The tutoring method employed is unique in several ways. It addresses the specific weaknesses most commonly responsible for failure on the NCLEX-RN (Kline, 2010; Poorman et al., 2010; Rollant, 2007; Simon et al., 2013; Woo et al., 2009). It is delivered within the context of a one-to-one relationship in which clients are supported emotionally, while simultaneously being held accountable for accomplishing the significant amount of work required. Clients are also encouraged to consider potentially beneficial lifestyle adjustments and are provided with strategies for managing their stress. The nugget method and six-step approach to analyzing test questions are each strategies that have facilitated client success. Empowering graduate nurses who have failed the NCLEX-RN is an intrinsically rewarding experience. Having the opportunity to form a bond with a graduate nurse and guiding him or her into a new life as an RN is an enormous privilege. Receiving an ecstatic, “I'm a nurse!” call or text from a former client is an experience not soon forgotten.
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The Six-Step Approach to Analyzing Questions
|1||Cover the answer choices and read only the stem and the question.|
|2||Rephrase the question in your own words to clarify the meaning.|
|3||Identify the key words in the stem and consider the implications of each.|
|4||Generate possible correct answers to the question, with the answer choices still covered.|
|5||Uncover the first answer choice and compare it with each key word in the stem. If it is incompatible with any of them, rule it out as the correct answer. Continue the process with the remaining answer choices.|
|6||Repeat the process with surviving answer choices, and choose your answer.|