Journal of Nursing Education

Major Article 

Analysis of Licensure Testing Patterns of RN Graduates in Oregon

Joanne Noone, PhD, RN, CNE, ANEF; Joy Ingwerson, MSN, RN, CNE; Amari Kunz, BSN, RN

Abstract

Background:

First-time NCLEX pass rate (FTPR) was a measure of workforce entry developed in the 1970s and is now used in accreditation standards to assess program effectiveness. Faculty may change admission and progression policies based on FTPR, which may affect enrollment, student diversity, or costs. This study describes testing patterns of RN graduates on the NCLEX-RN in Oregon to identify other academic metrics related to licensure.

Method:

Testing patterns of graduates in Oregon (N = 4,045) during 2013–2015 were analyzed to determine the number of testing attempts and length of time until success.

Results:

The FTPR for testers was 88.6%. By the second attempt, 96.1% passed; by the third attempt, 98% passed. Within 90 days of eligibility, 87.6% of testers passed; within 180 days, 95.3% passed.

Conclusion:

It is recommended that second- and third-time pass rates or pass rates within 6 months be considered as academic metrics for accreditation purposes. [J Nurs Educ. 2018;57(11):655–661.]

Abstract

Background:

First-time NCLEX pass rate (FTPR) was a measure of workforce entry developed in the 1970s and is now used in accreditation standards to assess program effectiveness. Faculty may change admission and progression policies based on FTPR, which may affect enrollment, student diversity, or costs. This study describes testing patterns of RN graduates on the NCLEX-RN in Oregon to identify other academic metrics related to licensure.

Method:

Testing patterns of graduates in Oregon (N = 4,045) during 2013–2015 were analyzed to determine the number of testing attempts and length of time until success.

Results:

The FTPR for testers was 88.6%. By the second attempt, 96.1% passed; by the third attempt, 98% passed. Within 90 days of eligibility, 87.6% of testers passed; within 180 days, 95.3% passed.

Conclusion:

It is recommended that second- and third-time pass rates or pass rates within 6 months be considered as academic metrics for accreditation purposes. [J Nurs Educ. 2018;57(11):655–661.]

Successful entry into the nursing workforce for graduates is an outcome for prelicensure nursing programs. The National Council of State Boards of Nursing (2015, para. 2) states: “Because passing the NCLEX is usually the final step in the nurse licensure process, the number of people passing the NCLEX (‘pass rate’) is a good indicator of how many new nurses are entering the profession in the U.S.” The first-time pass rate (FTPR) of nursing program graduates is a statistic that has been reported for many years with a consistent definition. The origin of how the NCLEX® FTPRs became a measure of undergraduate educational program quality is unclear but can be traced to a time when testing only occurred twice per year (Benefiel, 2011). At the time, it “was the only measure within a reasonable time period” to assess program effectiveness given that a first-time failure on the licensure examination would considerably delay entry into the workforce (Bernier, Helfert, Teich, & Viterito, 2005, p. 39). The FTPR is currently used in national accreditation standards (Accreditation Commission for Education in Nursing, 2017; Commission on Collegiate Nursing Education, 2013; National League for Nursing, 2016), as well as by state boards of nursing to assess program ability to prepare entry-level nurses.

Graduates today have multiple opportunities to test throughout the year. With the ease of today's computerized registration and testing, it is feasible for candidates to fail and retest and still enter the workforce within a reasonable amount of time. Because individual variation, such as readiness for testing, testing anxiety, and illness on the day of testing, influences testing outcome (Eddy & Epeneter, 2002; McFarquhar, 2014), is the FTPR still an appropriate metric to assess program quality and ability to prepare entry-level nurses? Recently, concerns have been raised about reliance on an outdated singular performance measure as an indicator of academic program quality and the influence that reliance on FTPR may have on stringent admission and progression policies that affect fulfillment of a school's mission and nursing workforce diversity (Giddens, 2009; Noone, 2017; O'Lynn, 2017; Taylor, Loftin, & Reyes, 2014).

The purpose of this study is to describe testing patterns of new graduates on the NCLEX-RN in Oregon to identify other potential licensure metrics related to educational program outcomes and entry of graduates into the nursing workforce. A retrospective analysis of new RN graduates' testing patterns in Oregon who graduated during the period from January 1, 2013, through December 31, 2015, identified patterns of numbers of testing attempts and length of time until successful licensure. This analysis provides an increased understanding of testing patterns of new graduates to inform the selection of a metric at the entry-level point that can be used as an indicator of the adequacy of the prelicensure educational programs to prepare their graduates for nursing practice.

Background

Currently, FTPRs are used as an outcome measure linked to educational quality by state and national nursing accrediting bodies. An 80% FTPR is the benchmark identified by the Commission on Collegiate Nursing Education (2013), the National League for Nursing Commission for Nursing Education Accreditation (National League for Nursing, 2016), and the Accreditation Commission for Education in Nursing (2017), although criteria varies by accrediting body (Table 1). State boards of nursing may have different FTPR benchmarks. Failure to achieve or maintain state or national benchmarks of FTPRs requires a programmatic plan and response. In Oregon, failure of one of the following is cause for a survey site visit:

  • A first-attempt pass rate of 60% or higher on the licensing examination over a 1-year period.
  • A first-attempt pass rate of 70% or higher over two consecutive 1-year periods.
  • A 2-year pass rate of 85% or higher over 3 consecutive years (Oregon State Board of Nursing, 2016).
Comparison of RN Licensure Pass Rates Accreditation Standards

Table 1:

Comparison of RN Licensure Pass Rates Accreditation Standards

Consequences to the nursing program of not meeting FTPR benchmarks include conditional accreditation status or loss of accreditation.

Nursing programs who do not achieve state board or national accrediting agency pass rate benchmarks may be asked to complete a self-study and remediation plan to bring an FTPR up to a benchmark. Adherence to state and national benchmarks for FTPR and monitoring by those agencies if benchmarks are not met require resource utilization by both nursing programs to address program review and the accrediting agencies to monitor resolution of concerns. Although all nursing programs need to be diligent in program evaluation activities, the focus of this effort may be linked too strongly for FTPRs at, near, or below benchmarks, with subsequent changes to the curriculum (i.e., additional courses or commercial standardized tests) that may not be supported by other evidence. Taylor et al. (2014) reported their experience of being placed on conditional status by state boards of nursing for FTPRs below accreditation standard. This drop in FTPRs occurred after increasing their enrollment in response to workforce needs. Follow up on graduates indicated passing on the second attempt with entry into the work-force. Despite this, admission and progression policies changes required by the state boards of nursing were instituted that decreased enrollment.

A variety of interventions to increase pass rates appear in the literature and include revising admission standards, curriculum review, changes in grading policies, standardized testing for admission or progression, additional coursework, faculty development, study skills, and stress management techniques (Carr, 2011; Pennington & Spurlock, 2010; Serembus, 2016). Pennington and Spurlock (2010), in a systematic review of remediation interventions to increase pass rates, identified that a variety of interventions were used to increase pass rates in the studies reviewed. However, there was a general lack of clarity about which interventions were of benefit and which were not. Although there are implications and cost to the graduate who fails upon the first attempt, such as additional costs of testing and a delay in entering the workforce, the costs of curricular changes must be considered by programs as well, especially when costs may be borne by the students.

Faculty may decide to implement programmatic changes to admission and progression policies based on FTPRs, which may impact student diversity or pose additional costs to the program or student through the implementation of standardized testing to assess the likelihood of graduates being successful on their first attempt on the licensure examination (Taylor et al., 2014). Giddens (2009), in an editorial aimed at rethinking FTPRs as the “gold standard,” cited the concern that as admission and progression policies are implemented in attempts to improve FTPRs, there is a risk of limiting access to diverse students who may struggle with standardized testing and the NCLEX because of linguistic issues. Eighty-eight schools of nursing in Texas were required by the Texas Board of Nursing to complete a self-study report during the years 2013–2015 due to low FTPRs. A common intervention identified in this analysis was raising admission standards, which was interpreted as accepting students with a higher grade point average or scores on standardized tests (Hooper & Ayers, 2017). Revision of admission policies is a remediation strategy identified by the Illinois Board of Nursing for schools of nursing who need to improve their FTPRs (Libner & Kubala, 2017). Of concern in selecting FTPRs as an outcome measure and then interventions based on predictors of FTPR success is the potential to develop admission policies with an increased emphasis on educational metrics, rather than a holistic review of academic metrics, individual experience, and individual attributes. This could further disadvantage admission of diverse students (O'Lynn, 2017; Taylor et al., 2014).

Additional responses to improve FTPRs may include implementation of remediation or progression policies, including use of standardized testing throughout the curriculum, adoption of high-stakes testing, or use of a single test for progression or graduation (Davenport, 2007; Stonecypher, Young, Langford, Symes, & Willson, 2015). Commercial standardized tests may be implemented throughout the curriculum with the costs of these tests often being borne by the student. Schroeder (2013) detailed implementation of a comprehensive testing policy including implementation of commercial standardized tests and progression policies throughout the program of study and reported a significant increase in NCLEX FTPRs from 89% before implementation to 97% after. It is interesting to note that the author reported an 89% FTPR before implementation of this rigorous set of initiatives, which exceeded both state (FTPR of 75% for the state of Colorado) and national benchmarks (80%) at baseline. It is unclear, if both state and national benchmarks are being met, what the rationale is for a comprehensive set of interventions. Although standardized testing has been demonstrated in limited studies to be effective in raising FTPRs (Carr, 2011), a systematic review of remediation interventions to increase FTPRs (Pennington and Spurlock, 2010) identified most studies of poor quality with limited generalizability.

Student variation in testing performance influences FTPRs and may be a variable independent of educational program quality. This has been demonstrated in multiple reports. Woo, Wendt, and Liu (2009) analyzed national registered and practical nursing licensure testing patterns over a 2-year period from 2006–2008 and determined that there was a significant decline in pass rates as lag time increased from eligibility to test to the actual test date. In a qualitative study of 19 graduates (10 who passed and nine who did not pass on the first attempt), Eddy and Epeneter (2002) were able to differentiate patterns of preparation for testing, readiness for testing, and stress management during the test. Those who failed on the first attempt more often reported feeling unready to test and described difficulties managing stress and distractions during the test. McFarquhar (2014), in a qualitative study of 18 graduates who failed the NCLEX, also reported perceptions of inadequate preparation and distractions that participants contributed to failure.

There have been recommendations to report and evaluate first- and second-attempt pass rates (Bernier et al., 2005; Giddens, 2009; Taylor et al., 2014) or pass rates within 1 year of graduation (Taylor et al., 2014). Bernier et al. (2005) questioned the use of FTPRs as the gold standard and cited concerns about FTPRs for use in smaller size programs, where the difference of one additional failure may have a large influence on the percent-based calculation of the FTPR. They also pointed out that national data only report FTPRs and repeat testing rates for testers in a calendar year without inclusion of when the tester graduated, the number of attempts, or time frame of success from graduation (National Council of State Boards of Nursing, 2015). Woo et al. (2009), in their national analysis of repeat testing, identified that successful testing declined upon repeat testing but did not identify the number of attempts associated with success.

The Canadian Council of Registered Nurse Regulators (2017), which recently adopted the NCLEX-RN, in addition to reporting FTPRs, also reported an ultimate pass rate, which is the percentage of testers taking the examination in the calendar year they graduated and who passed within a maximum of three attempts. This is in contrast to the United States, in which national data report only FTPRs and repeat testing rates for the year in which someone tested, regardless of their graduation date (National Council of State Boards of Nursing, 2015). Table 2 demonstrates a comparison of data collected by National Council of State Boards of Nursing and Canadian Council of Registered Nurse Regulators for the year 2015. The Canadian Council of Registered Nurse Regulators data provide clear information, especially when presented at a state and program level, of successful entry into the workforce within a given time frame from graduation. Most recently, Spector, Hooper, Silvestre, and Qian (2018) identified licensure pass rates as a common outcome measure that along with graduate and employment rates are metrics that “are only supported by opinion and not by high-level evidence” (p. 28). They recommend more evidence in identifying outcome metrics. The National Council of State Boards of Nursing is currently convening a Nursing Education Outcomes and Metrics Committee to recommend robust outcome measures (Spector, 2017).

Comparison of NCLEX-RN® Selected Results in United States and Canada for 2015

Table 2:

Comparison of NCLEX-RN® Selected Results in United States and Canada for 2015

Method

A retrospective, descriptive design was used for this study. New RN graduates' testing patterns in Oregon were analyzed to identify patterns of numbers of testing attempts and length of time until successful licensure. Assessing length of time until successful entry into the workforce is relevant given that the original measure of the FTPR was developed at a time when a failure meant a wait time of months to retest. The specific aims of this study were to:

  • Evaluate the number of testing attempts on the NCLEX-RN until success for all new graduates in Oregon who graduated in the time period of January 1, 2013, through December 31, 2015. These will be reported in aggregate and according to nursing program (anonymized) attended.
  • Evaluate the length of time until successful completion of the NCLEX-RN from eligibility to test for all new graduates in Oregon who took their first attempt during the period from January 1, 2013, through December 31, 2015. These will be reported at 3-, 6-, and 12-month intervals from eligibility to test and categorized in aggregate and according to nursing program (anonymized) attended.

Institutional review board approval by Oregon Health & Science University was received for this study.

Data records from the Oregon State Board of Nursing included individual test reports linked to the nursing program attended and educational first-time pass rates by nursing program for each of the 3 years. New graduates who were new candidates during this time period were identified, linked to a nursing program, and coded for anonymity. Follow-up on testing patterns occurred until December 31, 2016, to measure 1 year out from the end of first attempt period of study. All data were reported at the aggregate level and for each year, as well as by nursing program. Comparisons of these data with initial FTPRs reported by nursing program were made. Nursing program pass rates were calculated for second and third attempts, and successful attempts at 3-, and 6-, and 12-month intervals. Nursing program pass rates were identified as at risk if the annual FTPR was 85% or lower as either for faculty intervention or a review by the board of nursing would trigger interventions to improve FTPRs.

Results

There were 4,045 graduates in Oregon who were first-time testers during this 3-year period: 1,340 in 2013, 1,383 in 2014, and 1,322 in 2015. The FTPR for all testers in the 3-year period was 88.6% (n = 3,583). The annual FTPR was 88.1% (n = 1,181) in 2013, 89.6% (n = 1,239) in 2014, and 88% (n = 1,163) in 2015. For all years, 96.1% (n = 3,887) of testers passed by the second try; 98% (n = 3,964) passed by the third try. 87.6% (n = 3,545) of testers passed within 90 days of eligibility; 95.3% (n = 3,854) of testers passed with 180 days. Table 3 provides the total and annual aggregate results of number of attempts and duration until success.

Aggregate Results: Number of Attempts and Duration Until Success

Table 3:

Aggregate Results: Number of Attempts and Duration Until Success

A total of 80 measures of annual nursing program pass rates over the 3-year period reflected 26 nursing programs in 2013 and 2014 and 28 nursing programs in 2015. Wide variation of FTPRs existed, with 17 of the 80 (21.3%) measures falling below 85%. However, 76 (95%) of the 80 measures had nursing program pass rates on second attempt above 90% and 78 measures (97.5%) had an annual nursing programs pass rate above 90% on the third attempt. There was more variation in pass rates within 90 days of eligibility, with only 46 measures (57.5%) reporting that 90% or above of graduates passed within 90 days. This variability decreased at testing within 180 days of eligibility, with 75 (93.8%) of the 80 measures reporting 90% or more of graduates passed at that point. Table 4 provides a distribution of annual nursing program pass rates.

Distribution of Annual Nursing Program Pass Rates (N = 80)

Table 4:

Distribution of Annual Nursing Program Pass Rates (N = 80)

Of the 80 measures of annual nursing programs pass rates over the 3-year period, 18 measures had FTPRs of 85% or lower and were identified as at risk. Of the 18 at-risk measures, 14 (77.8%) had a second-time pass rate above 90% and 16 (88.9%) had a third-time pass rate above 90%. Table 5 provides annual pass rates for selected nursing programs identified as at risk. There was a wider variability in pass rates within 90 days for these 18 annual nursing program rates, with only one program achieving a pass rate above 90% within 90 days. However, by 180 days, 13 (72.2%) had pass rates exceeding 90%.

Annual Pass Rate Data for Selected At-Risk Nursing Programs

Table 5:

Annual Pass Rate Data for Selected At-Risk Nursing Programs

Discussion

This study had several limitations. The data reports from the board of nursing only included the graduation month and year, not the specific graduation day. Graduation dates were based on the end of the academic calendar for the specific nursing program either identified by the website or contacting the nursing program for the information. This may have influenced the findings of duration until success. The data reports for graduation date and nursing program attended are based on candidate report on the application for licensure. Although efforts were made to correct any known errors, some graduates could have been attributed to the wrong nursing program, affecting the calculation of individual nursing program pass rate results.

In addition, this study was limited to one state, although the findings in this study are reflected in the Canadian national data presented in Table 2. Although this study informed testing patterns of Oregon candidates and has the potential to engage a national dialogue to consider measures other than the FTPR as an outcome measure for educational programs, it is recommended that this study be replicated in other states to track testing patterns. Oregon is a small state and there may be less impact to smaller states or states with smaller numbers of nursing programs to consider a different academic metric. However, even in smaller states, the impact or cost to the individual student or program can be considerable, resulting from implementation plans to correct FTPRs. In the study by Hooper and Ayers (2017), 61 of the 88 schools in Texas required to submit a plan during to FTPRs in the period 2013–2015 were RN programs. An analysis of these schools' second-time pass rates or pass rates within 6 months in determining a need for a plan would be revealing and a contribution to understanding the evidence of FTPRs as an academic metric.

First-time pass rates, as well as when graduates first test, are influenced by tester variability; this was especially true for pass rates within 90 days of eligibility, which demonstrated a wider variability influenced by when graduates decide to test. In this study, over 95% of those who tested during the observed 3-year period passed the NLCEX-RN within 180 days of graduation. This finding, coupled with the ability to retest as soon as 45 days, provides support that there are other reasonable measures of entry into the workforce than the FTPR and support the advocacy positions presented in earlier nursing literature to consider outcome measures other than the FTPR. For all years, 96.1% of testers passed by the second try. The overwhelming majority of at-risk schools as identified by lower FTPRs had strong aggregate pass rates upon second attempt. It is recommended that second- and third-time pass rates within a year or pass rates within 6 months be considered as academic metrics for program outcome measures and for accreditation purposes. It is strongly recommended that nursing programs and state and national accrediting bodies assess pass rates upon second attempt before initiating admission, enrollment, or progression policy changes. Further understanding of patterns of successful licensure testing and readiness to enter the workforce will assist in selecting reasonable, evidence-based measures to inform curricular and program policies and maximize resource utilization and expenses for nursing students, nursing programs, and regulatory agencies. As nurse educators, we expect our graduates to use the best evidence and outcome measures available in clinical practice situations. It is time to reconsider whether FTPRs are the best outcome measure of academic quality of prelicensure nursing programs.

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Comparison of RN Licensure Pass Rates Accreditation Standards

Accrediting BodyLicensure Pass Rates Criteria
Commission on Collegiate Nursing Education (2013)The NCLEX-RN® pass rate for each campus/site and track is provided for each of the 3 most recent calendar years. “The NCLEX-RN pass rate for each campus/site and track is 80% or higher for first-time takers for the most recent calendar year. However, if the NCLEX-RN pass rate for any campus/site and track is less than 80% for first-time takers for the most recent calendar year, (1) the pass rate for that campus/site or track is 80% or higher for all takers (first-time and repeat) for the most recent calendar year, (2) the pass rate for that campus/site or track is 80% or higher for first-time takers when the annual pass rates for the 3 most recent calendar years are averaged, or (3) the pass rate for that campus/site or track is 80% or higher for all takers (first-time and repeat) when the annual pass rates for the 3 most recent calendar years are averaged” (p. 20).
National League for Nursing Commission for Nursing Education Accreditation (2016)“The program achieves a minimum graduate licensure pass rate of 80% among first-time takers, averaged over the most recent 3-year calendar time period, for each prelicensure program (practical/vocational, diploma, associate, and bachelor's), producing graduates eligible to seek licensure” (p. 10).
Accreditation Commission for Education in Nursing (2017)“The program's most recent annual licensure examination pass rate will be at least 80% for all first-time test-takers during the same 12-month period” (p. 6).

Comparison of NCLEX-RN® Selected Results in United States and Canada for 2015

United StatesDefinitionCanadaDefinition
Total = 229,459The number of candidates taking the examination and seeking U.S. licensure in 2015.Total = 9,048The number of graduates in 2015 who took the examination in Canada.
First-time = 166,523 (81.78%)The number is the number of first-time testers who took the exam in 2015 and the percentage is the percentage of candidates passing the examination on the first attempt regardless of graduation date.First attempt pass rate = 6,306 (69.7%)Percentage of graduates in 2015 who passed the examination on the first attempt.
Repeat = 62,936 (38.36%)The number is the number of repeat testers who took the examination in 2015 and the percentage is the percentage of candidates passing the examination on a repeat attempt regardless of graduation date.Ultimate pass rate in 2015 = 7,605 (84.1%)Percentage of testers who graduated and took the examination in 2015 and passed within a maximum of three attempts.

Aggregate Results: Number of Attempts and Duration Until Success

MeasureTotal201320142015
Number of testers4,0451,3401,3831,322
First-time pass rate3,583 (88.6%)1,181 (88.1%)1,239 (89.6%)1,163 (88%)
Pass rate by second attempt3,887 (96.1%)1,290 (96.2%)1,335 (96.5%)1,262 (95.5%)
Pass rate by third attempt3,964 (98%)1,319 (98.4%)1,356 (98%)1,289 (97.5%)
Pass within 90 days3,545 (87.6%)1,170 (87.3%)1,234 (89.2%)1,141 (86.3%)
Pass within 180 days3,854 (95.3%)1,272 (94.9%)1,325 (95.8%)1,257 (95.1%)
Pass within 365 days3,959 (97.6%)1,307 (97.5%)1,354 (97.9%)1,298 (98.2%)

Distribution of Annual Nursing Program Pass Rates (N = 80)

Nursing Program Pass RateFirst-Time Pass RatePass Rate by Second AttemptPass Rate by Third AttemptPass Rate Within 90 DaysPass Rate Within 180 Days
65% to 69%0 (0%)0 (0%)0 (0%)3 (3.8%)0 (0%)
70% to 74%3 (3.8%)0 (0%)0 (0%)3 (3.8%)0 (0%)
75% to 79%4 (5%)0 (0%)0 (0%)5 (6.3%)0 (0%)
80% to 84%10 (12.5%)1 (1.3%)0 (0%)10 (12.5%)2 (2.5%)
85% to 89%19 (23.8%)5 (6.3%)2 (2.5%)13 (16.3%)3 (3.8%)
90% to 94%21 (26.3%)18 (22.5%)5 (6.3%)23 (28.8%)26 (32.5%)
95% to 100%23 (28.8%)56 (70%)73 (91.3%)23 (28.8%)49 (61.3%)

Annual Pass Rate Data for Selected At-Risk Nursing Programs

Nursing ProgramCohort SizeFirst-Time Pass Rate (%)Pass Rate by Second Attempt (%)Pass Rate by Third Attempt (%)Pass Rate Within 90 Days (%)Pass Rate Within 180 Days (%)
123781.4394.9497.4783.9795.36
2207590958095
32975.8689.6610072.4193.10
417081.7692.9496.478090
53582.8691.4397.2282.8691.43
61681.2510010093.7593.75
72180.9595.2410080.9585.71
820859510080100
93778.3889.1997.3072.9789.19
1019082.1193.6895.7982.6393.16
111384.6292.3192.3184.6292.31
1210281.3792.1695.1079.4192.16
131872.2288.8988.8977.7783.33
144780.8595.7497.8765.9691.49
1519078.4292.6398.4275.7991.58
1619681.1293.8797.4584.1893.37
177173.2483.1088.7373.2481.69
181973.6889.4794.7368.4284.21
Authors

Dr. Noone is Associate Professor, and Ms. Kunz is Graduate Student, School of Nursing, Oregon Health & Science University, and Ms. Ingwerson is Policy Analyst, Nursing Education and Assessment, Oregon State Board of Nursing, Portland, Oregon.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Joanne Noone, PhD, RN, CNE, ANEF, Associate Professor, School of Nursing, Oregon Health & Science University, 1250 Siskiyou Boulevard, Ashland, OR 97520; e-mail: noonej@ohsu.edu.

Received: January 27, 2018
Accepted: May 01, 2018

10.3928/01484834-20181022-05

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