Successful completion of the licensure examination has become synonymous with the quality of educational preparation received by students in baccalaureate programs. Pass rates serve as a key indicator of the achievement of a program's academic goals. Pass rates are incorporated into the accreditation process of programs and in many states, first-attempt NCLEX-RN pass rates are a key component of the state board approval process.
Coupled with the significance of program pass rates are the recent changes to the NCLEX-RN examination by the National Council of State Boards of Nursing. Initial changes to computerized testing in 1994 and the recognition of the ongoing need to evaluate the efficacy of the examination have served to focus academic programs on NCLEX-RN preparation activities. Subsequent changes to the difficulty level in 2004, 2010, and 2013 also serve as contributing factors (National Council of State Boards of Nursing, 2018).
Each state board of nursing establishes criteria for determining the NCLEX-RN pass rate. States govern the methodology for calculating a program's pass rate, and in many states, the pass rate for first attempts on the examination are used in the state board's program evaluation and approval processes. In many states, such as Pennsylvania, programs not achieving a composite score of 80% on first attempts are placed on provisional status, and if not corrected, may ultimately be placed on probation. In Pennsylvania, scores included in the calculation of first-attempt pass rates occur from October 1st through September 30th of the following year.
To address accreditation issues related to NCLEX-RN pass rates, as well as to meet programmatic goals, prelicensure nursing programs need to incorporate strategies to improve the overall success of their graduates on the licensure examination. The development of these strategies is contingent on the identification of predictors of NCLEX-RN success. The purpose of this retrospective analysis was to examine various programmatic components and their relationships to first-attempt NCLEX-RN pass rates.
Nursing literature reflects the trend toward assessment of multiple factors for success and the implementation of a variety of strategies for student preparation for the licensure examination. Traditional measures of student success have included grade point average (GPA), standardized testing scores, scholastic aptitude test (SAT) scores, and admission and progression criterion, which may include interviews and written essays (Romeo, 2013).
There is a long-standing history of baccalaureate programs implementing standardized testing strategies to increase NCLEX-RN readiness (Carr, 2011; Daley, Kirkpatrick, Frazier, Chung, & Moser, 2003; Frith, Sewell, & Clark, 2005). Studies reported that various comprehensive standardized testing packages increased NCLEX-RN pass rates (Homard, 2013; Hyland, 2012). Historically, there has been an evolution from using stand-alone testing to comprehensive programming that includes standardized testing along with various teaching–learning strategies (Hyland, 2012; Serembus, 2016; Wiggins, 2012).
The NCLEX-RN preparation programs have become more formalized to include the evaluation of various factors contributing to student learning. In turn, baccalaureate programs are currently being evaluated to assess predictors of both NCLEX-RN readiness and success among students, as well as areas for program improvement (Simon, McGinniss, & Krauss, 2013).
In 2014, Wilkes University's Passan School of Nursing became a free-standing school within the university. Under new leadership, a change in organizational structure was implemented and faculty members teaching in the prelicensure nursing programs were tasked with addressing the decline in first-attempt NCLEX-RN pass rates experienced within the prior 2 consecutive years.
Various strategies were planned to address the low NCLEX-RN pass rates. A comprehensive mentoring program was designed and implemented for both the traditional baccalaureate and the accelerate baccalaureate programs. In this comprehensive mentoring program, faculty members were assigned to a group of students. For traditional students, one faculty mentor was assigned to a group of eight to nine students. For accelerated students, the program coordinator served as the mentor. Faculty mentors facilitated engagement of their assigned students in formal NCLEX-RN review courses, computerized learning platforms, and total testing packages. Students in the traditional prelicensure program were also engaged in a formalized gaming agenda. Faculty mentors served as coaches for their students during gaming activities.
During the study period, students were required to obtain a minimum score of 800 on the Health Education Systems, Inc.™ (HESI) Exit Exam for the first 2 years of implementation and subsequently a minimum score of 850 in the third year. All students received a 3-day review course prior to taking the HESI Exit Exam for the first time. All students in the sample completed a comprehensive final patient simulation and were scored using the Lasater Clinical Judgment Rubric (LCJR).
After 3 years of implementation, these strategies were explored for their effect and contribution to NCLEX-RN success. Analysis was conducted to answer the research question: What are the predictors of first-time NCLEX-RN success when a comprehensive mentoring program is implemented?
A retrospective analysis was performed to examine programmatic components addressed through a comprehensive mentoring program in the Passan School of Nursing for their relationships to first-attempt NCLEX-RN pass rates. A logistic regression analysis was planned and conducted to identify factors predictive of success on the first-attempt of the NCLEX-RN.
The study received approval from the Wilkes University Institutional Review Board. Permission was granted for use of deidentified, aggregate data, representing both traditional and accelerated students.
The sample consisted of all students who had graduated from the traditional and accelerated baccalaureate nursing programs from May 2015 through May 2017 (n = 208). In accordance with school policy, all participants achieved a 2.5 or greater GPA (2.5 GPA = 79 numerical value) in all nursing courses throughout the program. All participated in a comprehensive mentoring program during the final two semesters of their traditional program or the last semester of their accelerated program.
Of the participants, 84.6% were female and 15.4% were male. More than half (92.3%) were under the age of 30, followed by 6.3% between ages 31 to 40, and 1.4% were older than 40 years. Most participants had an overall GPA between 3.4 and 3.49 (58.7%), followed by a GPA between 2.5 and 2.99 (22.1%), and the remaining had a GPA greater than 3.5 (19.2%). The sample consisted of 158 (76%) traditional prelicensure Bachelor of Science in Nursing students, 40 (19.2%) accelerated Bachelor of Science in Nursing program students, and 10 (4.8%) licensed practical nurse-Bachelor of Science in Nursing students.
From the various strategies used in the comprehensive mentoring program, three were selected for evaluation as potential predictors of NCLEX-RN first-time pass: (a) cumulative GPA, (b) HESI Exit Exam first-time score, and (c) score on the LCJR for the final comprehensive simulation.
GPA is defined as the total number of quality points divided by the number of credits earned for all courses completed as an undergraduate student at the University. The HESI Exit Exam is a standardized examination that is designed to serve as a predictor of success on the licensure examination. The typical cut score for success is 850. At the 900 level, the examination is 97% accurate in predicting NCLEX-RN success (Langford & Young, 2013). The LCJR is a rubric designed to assess clinical nursing judgment development in prelicensure nursing students and categorize this judgment as beginning, developing, accomplished, or exemplar (Lasater, 2007).
A database was created using SPSS® version 23. Student data were deidentified and entered into the database. Correlation and logistic regression analyses were performed to identify study variables that were predictive of NCLEX-RN success in the study sample.
A total of 208 participants were included in the initial study. One student did not take the NCLEX-RN and data for this student were not included in the analysis, resulting in a sample size of 207. Pearson correlations were calculated for first-time HESI Exit Exam scores, first-time NCLEX-RN pass, LCJR final scores, and total GPAs. NCLEX-RN pass was significantly correlated with first-time HESI Exit Exam scores (r = .386; p = .000) and total GPA (r = .337; p = .000). NCLEX-RN pass rates were not significantly correlated with final LCJR scores. Other significant correlations exist between HESI Exit Exam scores and total GPA (r = .481; p = .000), and LCJR and total GPA (r = .191; p = .006). On the basis of the weak positive correlation between LCJR and total GPA, the decision was made to include LCJR in the logistic regression analysis.
Logistic regression analysis was conducted. Total GPA, first-time HESI Exit Exam scores, and LCJR final scores were entered as predictor variables and NCLEX-RN pass rate was entered as the outcome variable. The Nagelkerke R square was .424, indicating that 42.4% of the outcome is accounted for by the predictor variables. The Hosmer–Lemeshow test was not significant at p = .995, indicating a good fit of the model.
Analysis revealed that total GPA and first time HESI Exit Exam scores were significant predictors of passing the NCLEX-RN. The odds ratio indicated that with increased GPA the odds of passing the NCLEX-RN examination increases. Students with higher GPAs are 167 times more likely to pass NCLEX-RN than individuals with lower GPAs (odds ratio [OR] = 167.529; p = .001). Students who score greater than 800 on their first attempt on the HESI Exit Exam also have increased odds of passing NCLEX-RN (OR = 1.011; p = .001); the LCJR was not significant.
Several limitations were inherent in the study methodology. This is a retrospective analysis of existing data; the study was limited by sample size and student characteristics. Due to the university admission policies, which include a focus on first-generation students and conditional admissions, there was limited flexibility in the contribution of decision making, which resulted in a lack of control on admission criteria and associated student ability. The next step would be to analyze the data, including final high school GPA as a possible predictor of academic success in a 4-year nursing program. Results may provide evidence in support of a more stringent admission policy that would lead to increased student success.
The logistic regression model explains approximately 42% of the variability in student success in passing the NCLEX-RN. Other unidentified factors would account for the remaining 58%. These may include teaching and learning styles, motivation, nonacademic obligations, generational differences, admission criteria, and other qualitative factors. It is clear that from these results the admission and progression criteria can influence success. If unable to change admission criteria, additional mechanisms to support student success would be needed.
Given the university mission of a high percentage of first-generation students, faculty mentorship is crucial for their success on the NCLEX-RN. A comprehensive senior mentoring program provides individualized support and structure in the student preparation process for the licensure examination. An implication for nursing education would be to expand the mentoring process throughout the nursing program, thus building to the senior year.
The relationship between GPA and LCJR also warrants further investigation. The weak positive correlation indicates that students with higher GPAs should have improved performance in the clinical setting. The school of nursing continues the mentorship program and adds to the sample size, additional data will be analyzed.
Moving forward, there is little research analyzing the consistency of state boards of nursing in the determination of pass rates of nursing programs (Foreman, 2017). Every nursing program must abide by the regulations put forth by their particular state. A recommendation for future policy revision is to first work at the state level, revising the methodology for program evaluation. This already has been attempted through an organization comprising of baccalaureate nursing education programs and was met with resistance. The next step would be to work toward national consistency in the evaluation of program outcomes as they relate to NCLEX-RN pass rates.
The exploration of a multiple factors as predictors of student NCLEX-RN success has led to the identification of GPA as a major predictor of licensure success. This has implication for setting the admission and progression criteria for nursing programs. Although HESI Exit Exam scores correlate with NCLEX-RN success, comprehensive mentoring programs are beneficial in assisting students with lower GPAs to reach NCLEX-RN success. The continued investigation, development, and implementation of comprehensive mentoring programs will facilitate ongoing student readiness for the licensure examination.
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