Every 3 months, nursing programs apprehensively hold their breaths as they receive their latest round of the National Council Licensure Examination (NCLEX) pass rates, and for good reason—few data hold as much power over a school's reputation, operations, and quality improvement actions as do first-time NCLEX pass rates. Pass rates are an example of performance data used to measure a specific outcome—in this case, initial success on the licensure examination by the graduates of a given program. Performance outcomes are widely used to evaluate an organization's ability to meet goals, address stakeholder's needs, and fulfill organizational mission and purpose. By extension, performance outcomes constitute essential indicators of organizational quality.
NCLEX success is a performance outcome used by nursing education accreditors and most boards of nursing as a criterion for evaluating nursing program quality and, in particular, academic quality. Other types of performance outcomes, such as program completion rates and employment of nursing graduates, are commonly used as well. However, those outcomes are less indicative of the quality of nursing programs than they might be in other disciplines, given that increasingly restrictive admission criteria and competition for available seats ensure that only the strongest students (and those more likely to graduate) enter nursing programs, and the strong demand for RNs ensures high employment for eligible graduates. Indeed, most programs experience favorable graduation and employment performance and typically exceed minimum levels of performance as defined by accreditors and regulators. With few other externally determined performance outcomes available, NCLEX success becomes, by default, the primary performance outcome and quality indicator of nursing program academic quality.
Emphasis on a solitary performance outcome defies sound evaluation principles (Yarbrough, Shulha, Hopson, & Caruthers, 2011) and has been strongly criticized by some in the academy (Giddens, 2009; Taylor, Loftin, & Reyes, 2014). Of particular concern are the well-described psychosocial–cultural variables germane to NCLEX success that are beyond the direct control and accountability of educational programs. These variables become more important as students who are more diverse and present with greater numbers of competing life demands, priorities, and values replace the more traditional students of previous decades. Furthermore, overemphasis on NCLEX success may impair some programs from holistically fulfilling their missions by diverting attention and resources away from developing student competencies in the caring and ethical arts, building teaching excellence and pedagogical expertise among faculty, and implementing innovative pedagogies and curricula that empower and facilitate success among diverse and nontraditional learners. Instead, programs too often rely on inconclusive evidence to support the implementation of narrowly focused actions, such as overly stringent admission practices, punitive progression policies, content cramming, and reactive remediation, to quickly turn around troublesome NCLEX pass rates (Serembus, 2016; Taylor et al., 2014). These actions may be efficacious in the short term, but one wonders at what cost to fully supporting students with diverse needs and preferences.
Far more numerous than performance outcomes in the external evaluation of nursing program academic quality are compliance criteria. Most of these criteria pertain to structures and processes, such as requirements that faculty have adequate office space, what must be included in a course syllabus, or the number of clinical hours required in a program of study. Some compliance criteria are sufficiently prescriptive so that a reviewer would have no question whether a program is in compliance. Other criteria are highly subjective and up to the reviewer's discretion. For example, just how much space is “adequate” for a faculty office? Compliance criteria establish minimum standards for program operations, academic integrity, financial stability, consumer protection, patient safety, and the like. Although compliance criteria have relevance and importance, many criteria do not necessarily ensure program quality. Spacious faculty offices may contribute to, but do not ensure, faculty's ability to develop courses or counsel students in a high-quality manner, nor does a specific number of hours of students' attendance at a clinical site ensure that students achieve clinical competencies. Indeed, quality is more likely due to faculty expertise, pedagogical perspectives and practices, and radical creativity than to the size of one's office or the number of hours a student is in a clinical setting.
It is time for serious rethinking of the quality indicators used to evaluate nursing program academic quality. Additional performance outcomes are needed that will counterbalance the skewed weight given to first-time NLCEX success yet are meaningful to nursing programs' general mission and purpose as centers of higher learning and the preparation of professional nurses. Possible examples might address areas pertaining to student and employer engagement in program development and evaluation, constituent satisfaction with students' preparation for beginning nursing practice, faculty performance, student clinical performance, diversity, and others. Discussion is warranted about which performance outcomes are most meaningful to academic quality and mission and which are amenable to standardized assessment. Consideration is also necessary to decide what would constitute reasonable minimum levels of achievement, even though discernment of levels of achievement may be subjective. After all, consensus is lacking among boards of nursing regarding what the minimum first-time NCLEX pass rate should be and how this measure should be used in appraising program quality (Serembus, 2016; Taylor et al., 2014) . With additional performance outcomes required of all nursing programs, it is possible that external reviewers would examine programs' performance on multiple outcomes before deciding whether deeper scrutiny of a nursing program is fully warranted.
A reexamination of compliance criteria is also needed. Although criteria vary greatly, accreditors and regulatory bodies should ensure that emphasis is given to compliance criteria that most meaningfully address the teaching and learning processes requisite for the successful preparation of tomorrow's nursing work-force. A sufficient evidence base of research and expert opinion already exists to inform this reexamination and guide the development of new compliance criteria. Three areas of revision are particularly warranted:
- Move away from specific curricular content requirements to curricular requirements that ensure students demonstrate specific practice-based competencies. Some nursing accreditors and boards of nursing have moved in this direction; the remaining need to follow suit. Programs should have the discretion and innovative freedom to select curricular content based on institutional mission, evidence, employer and alumni feedback, and pedagogical expertise of faculty, although programs must be accountable for explicit mapping of their curricula to the competencies required for licensure and practice and for demonstrating unequivocal student achievement of competencies.
- Programs, and curricula in particular, should be aligned to pedagogical principles and perspectives. Programs typically are required to articulate how curricula and operations support institutional mission and purpose. The necessity of this requirement may seem obvious, but most mission and purpose statements are visionary and so broadly stated that almost any curriculum and program operation could be shown to be supportive and aligned with institutional mission. Many programs also align curricula with philosophy statements or conceptual frameworks, yet statements and frameworks typically pertain to nursing practice or health care. This is not sufficient. Programs should be required to articulate the pedagogical principles or models shared among the faculty upon which learning activities and curricula are designed and implemented. In other words, pedagogical perspectives should guide teaching and learning, rather than perspectives on what constitutes the discipline of nursing.
- Programs should be required to ensure that faculty have preparation in the specialty of nursing education. Nursing boards and accreditors generally require that nursing faculty have a graduate nursing degree and experience or content knowledge relative to the courses for which they are assigned. Such requirements help ensure important content expertise but do little to ensure that faculty have preparation for their primary roles as educators. Faculty should be required to have either academic preparation in nursing education, previously demonstrated educator expertise, or formal preparation as a nurse educator within a specified time frame. Clearly, such a requirement has important operational implications, but failure to reconsider compliance criteria relative to faculty qualifications only perpetuates the misguided acceptance that clinical expertise sufficiently translates into educator proficiency.
Most important, internal conversations and published opinions are insufficient actions for change in and of themselves. The National League for Nursing and the American Association of Colleges of Nursing should take advantage of their positive relationships with the National Council of State Boards of Nursing to advocate for further exploration of these issues and provide a national call for member states to reexamine existing performance outcomes and compliance criteria used for evaluating a program's academic quality. Further, nursing program leaders within each state must vocally unite on this concern and collaborate frequently and intensively with their nursing education representatives on their respective boards of nursing or other licensing bodies. Collectively, they should identify possible revisions to specific rules and regulations to allow for more appropriate determinants of academic quality and mitigation of the over-reliance on first-time NCLEX success. Finally, we must all work closely with our nursing accrediting bodies to ensure that the preference for maximum flexibility in the interpretation and application of accreditation standards does not come at the expense of inclusion of diverse and concretely understood performance outcomes and compliance criteria. This three-pronged action plan, at a minimum, should further the discussion with the institutions empowered to make the necessary changes. Failure to act will only sustain the status quo.
Chad O'Lynn, PhD, RN, CNE, ANEF
Director of Evaluation and Innovation
Chamberlain College of Nursing
- Giddens, J.F. (2009). Changing paradigms and challenging assumptions: Redefining quality and NCLEX-RN pass rates. Journal of Nursing Education, 48, 123–124. doi:10.3928/01484834-20090301-04 [CrossRef]
- Serembus, J.F. (2016). Improving NCLEX first-time pass rates: A comprehensive approach. Journal of Nursing Regulation, 6(4), 38–44. doi:10.1016/S2155-8256(16)31002-X [CrossRef]
- Taylor, H., Loftin, C. & Reyes, H. (2014). First-time NCLEX-RN pass rate: Measure of program quality or something else?Journal of Nursing Education, 53, 336–341. doi:10.3928/01484834-20140520-02 [CrossRef]
- Yarbrough, D.B., Shulha, L.M., Hopson, R.K. & Caruthers, F.A. (2011). The program evaluation standards: A guide for evaluators and evaluation users (3rd ed.). Thousand Oaks, CA: Sage.