First-time NCLEX-RN pass rates are often used as an important criterion to evaluate the effectiveness of prelicen-sure nursing programs (Taylor, Loftin, & Reyes, 2014). This article describes student coaching as one specific strategy that a prelicensure baccalaureate nursing program implemented as part of a comprehensive improvement plan to address declining pass rates. Pass rates had dropped from 85.71% to 64.86% over a period of 4 years and the program faced sanctions from the State Board of Nursing, as well as concerns about meeting standards set by accreditors. Negative publicity about the pass rates led to declines in enrollment, and the program had reached a crisis moment. Strategies were implemented within the program that focused on curricular, faculty, and student factors (Czekanski, Hoerst, & Kurz, 2018) with one intervention, coaching, specifically targeted on closing the loop on graduates' preparedness for taking the NCLEX-RN.
Beginning in 2012, the program was awarded a Health Resources and Service Administration Nursing Workforce Diversity grant and established a tutoring center known as Strategies for Success. The center was initially designed to provide individual sessions for diverse, underserved students. Tutoring sessions focused on study habits, time management, and test-taking skills. Students were introduced to the center, and demand for services increased and program resources were used to extend tutoring services to all nursing students.
Meanwhile, as the nursing program addressed curricular standards and implemented more rigorous progression criteria to address first-time NCLEX-RN pass rates (Czekanski et al., 2018), it became apparent that students needed additional support. In the fall of 2014, the program had its third consecutive first-time pass rate below the state mandated rate of 80%. Although policies had been put in place to ensure students would meet selected benchmarks within the program to graduate, some students who were expected to pass the licensure examination on the first attempt were not successful. These students had met all course requirements, a standardized testing benchmark, specifically a Exit Exam HESI score of at least 850 and had completed the required in person NCLEX-RN review course.
With the demonstrated success of the tutoring center, the university decided in the fall of 2015 to fund a full-time position of Tutor and Retention Coordinator (TRC). The position was created with the goal of increasing the retention of undergraduate nursing students from enrollment to graduation and improving and maintaining first-time licensure pass rates above the national average. The ideal TRC candidate was expected to be a master's-prepared nurse with a solid knowledge base in nursing, testing-taking strategies, and excellent interpersonal skills and demonstrated abilities to problem solve and work autonomously. The individual chosen as the TRC was a former clinical nursing adjunct faculty member who had worked as a part-time tutor with the Strategies for Success Center. This new role was designed to increase the interaction with students, improve their self-efficacy, and provide a personal support system. An additional role taken on by the TRC was an in-depth evaluation of the data on student and graduate performance on benchmark measures. This led to the confirmation that although tutoring overall had helped students to meet the new progression and end-of-program requirements, it appeared that graduates needed additional support to complete their journey toward becoming a professional nurse. The TRC responded by initiating the coaching intervention using strategies reported as effective in the literature and strategies to address specific factors identified by the program's graduates as adversely influencing their testing performance.
The literature speaks to reasons for declining pass rates, such as delaying testing after graduation, test anxiety, personal events and responsibilities; and inadequate preparation for the examination on the first attempt (Johnson, Sanderson, Wang, & Parker, 2017; Khalaila, 2015; Libner & Kubala, 2017; Pressler, & Kenner, 2012; Shoemaker, Chavez, Keane, Butz, & Yowler, 2017; Silvestri, Clark, & Moonie, 2013). Armed with this information and additional information gathered from personal interviews with graduating seniors and recent graduates, the TRC implemented the postgraduation “coaching” intervention beginning with the graduating class of January 2016.
Given that it was known that some graduates were failing the NCLEX-RN who were not deemed at risk on the basis of their academic profile, all graduates were targeted. The TRC and the chief nurse administrator of the program met with the students during their senior seminar course to describe the intervention and encourage them to attend. The Senior Seminar course is a one-credit course offered in the last semester of the program. The focus of the course is on the synthesis of nursing clinical concepts and enhancement of critical thinking and test-taking skills. Students were informed that this was a free NCLEX-RN support session that would be customized to meet their needs.
This postgraduation coaching intervention was designed to assist the students in developing an individualized study plan as they prepared for the NCLEX-RN using several approaches, including cognitive behavioral techniques, content reviews, and test-taking strategies. One week after completion of their face-to-face review course, students were e-mailed invitation to attend an NCLEX-RN group support session. Sessions were offered at a variety of times to increase accessibility for students and were open to all interested students. Students were encouraged to organize their attendance around work schedules and vacations, and on average 10 to 20 students attended each session. Group sessions were highly recommended, but individualized sessions were also made available by appointment. Students who could not attend the live sessions were also offered a modified version of this support via telephone, text messaging, or e-mail. The TRC found text messaging to be an effective communication tool with all participants.
At the initial group NCLEX-RN support session, a presentation discussing facts or fiction associated with the NCLEX-RN was shown to the students. Although the specific instructions related to the licensure examination itself (e.g., timing, application, payment) had been presented during their senior seminar course, students had not comprehended all the details due to the stress of finals and completing graduation requirements. Students were given the opportunity to discuss any myths they might have heard about the examination, and facts with direct reference to the National Council of State Boards of Nursing (2017) website were presented. This information included content such as the potential length of the examination, types of questions, including alternate-format questions, and the passing standard. The NCLEX-RN examination blueprint was also carefully reviewed to indicate the distribution of questions across the client needs categories. The registration process with the State Board of Nursing and with the Pearson VUE testing company was discussed and at this point many students were waiting for their Authorization to Test from the State Board of Nursing. Students were encouraged to take the NCLEX-RN within 4 to 6 weeks of graduation to avoid a decline in their nursing knowledge, skills, and abilities (Woo, Wendt, & Liu, 2009).
Students were asked to verbalize their fears and anxieties regarding the NCLEX-RN. Consistent with the literature (Libner & Kubala, 2017), students at this time often reported anxiety related to how to prepare for the NCLEX-RN and fear of failure. The goal of this session was for the TRC to assist students to confront their fears and to provide them with specific cognitive behavioral and test-taking strategies to develop their individualized study plan. The aim was to motivate the students to take the examination preparation seriously so they would be successful on their first attempt. Students were encouraged to dedicate 3 to 4 hours daily to adequately prepare for the examination, remove all distractions from their environment (e.g., telephones and other electronic devices), choose a study time when they were most alert, and use a library or another quiet location to maximize their preparation. Students who were employed full time were urged to decrease their work hours as they prepared for the NCLEX-RN.
All students are required to complete an approved in-person nationally recognized NCLEX-RN review course to complete nursing program requirements. Given that many graduates had taken a Kaplan Review course (Kaplan Nursing, 2017), the TRC assisted graduates on maximizing the use of the Kaplan resources such as the Qbank®, an online question bank; question trainers; and the diagnostic NCLEX-RN practice and readiness tests (Kaplan Nursing, 2017). Students were individually assessed on scores on trainer examinations, whether they were using the study/tutor or test mode, the examination length and time on questions, test fatigue, and speed, accuracy, and persistence. Students were encouraged to practice questions in the test mode. Although the tutor mode allowed students to view test item rationales immediately and gave them the instantaneous satisfaction of knowing whether their answer was correct, the test mode allowed the student to simulate an accurate prediction of NCLEX-RN success. Students were also encouraged to complete Qbank examinations with a minimum of 75 questions to simulate the NCLEX-RN. During these examinations, graduates were encouraged to assess the time it took them to complete the questions, the percentage correct according to the NCLEX-RN blueprint, and the patterns of incorrect responses to determine test fatigue. In this group session, many students reported at least five consecutive incorrect questions at approximately questions 40 to 45 or 70 to 75, especially when multiple alternate-format questions were in the mix. Students were encouraged to incorporate breaks, even mental breaks, at the item number where they received five or more consecutive test items incorrect.
Given that the benchmark as it relates to accuracy and NCLEX-RN predictor is 60% to 65% for Kaplan, the TRC evaluated each graduate's overall trainer/Qbank score in addition to the NCLEX-RN blueprint score. For example, if the score in the management of care section was only 45%, students were encouraged to formulate a Qbank examination with 75 test items to effectively remediate this area. In every area where the student's score was lower than 65%, the student was encouraged to formulate specific Qbanks examinations prior to proceeding to a new Qbank examination or trainer. Students were also encouraged to remediate all incorrect items from trainers, carefully examining rationales and asking themselves “why did I get this question incorrect?” Students were asked to be honest, as the goal was to assess content knowledge and test-taking strategies. Students who reported content deficits were asked to examine that specific content in the Saunders Comprehensive Review for the NCLEX-RN® Examination textbook (Silvestri, 2017). If the student reported challenges with test-taking strategies, then a specific session on improving those skills was organized.
Time was also spent on the best use of resources. Resources that were encouraged were the Kaplan resources (Kaplan Nursing, 2017), Elsevier Adaptive Quizzing for the NCLEX-RN Exam (Elsevier, 2017), and the Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEXRN® Examination textbook (LaCharity, Kumagai, & Bartz, 2018). Students were asked to share any additional resources they found to be particularly effective.
The management of care section, comprising 17% to 23% of the NCLEX-RN (National Council of State Boards of Nursing, 2016), was emphasized and all students, but specifically individual students who scored below the 65% benchmark on their Kaplan management of care Qbank, were invited to participate in a delegation and prioritization simulation. In this simulation, the TRC, with the assistance of the Nursing Learning Resource Coordinator, developed a scenario involving five hospitalized patients with varying health issues. The objective of the simulation was to increase the students' understanding of how to manage, prioritize, and delegate the appropriate tasks and skills for this group of patients whose care focused on fundamental and medical–surgical nursing interventions, as well as maternity care. These areas were specifically chosen given that the student performance in the Fundamentals, Exit, and Maternity HESI examinations has been found to be predictive of NCLEX-RN outcomes (Schooley & Kuhn, 2013).
In the simulation, students were assigned roles such as charge nurse, staff nurse, licensed practical nurse, and unlicensed assistive personnel. The simulation highlighted the roles and responsibilities of each team member, with a focus on the tasks that could be safely delegated. This was especially valuable given that the students had limited experience in delegating to licensed practical nurses and unlicensed assistive personnel. In fact, many of the clinical agencies where students had been placed as students were Magnet®-designated organizations who did not employ licensed practical nurses. This experience guided students on the decision-making process that they could apply to management of care NCLEX-type questions. At the conclusion of each NCLEX-RN support session, all attendees left with an individualized study plan based on their specific needs and were encouraged to implement the interventions prior to the next session.
A follow-up NCLEX-RN support session typically included a presentation by a former graduate who had recently been successful on the NCLEX-RN. This new RN shared his or her first-hand experiences regarding the NCLEX-RN process, including examination preparation and resources that were specifically helpful. At this point, many attendees had received their Authorization to Test and wanted to discuss whether their test date was realistic. The TRC encouraged students to use the performance on their practice examinations as evidence of their readiness to test; however, at this moment, their anxiety was often increasing. This anxiety was evident in the graduates' verbalizations and, in some cases, a decrease in Qbank scores. For some, this decrease in scores was in the range of 10 to 20 points.
Cognitive behavioral interventions used at this time included such strategies as cognitive restructuring and visual imagery (Poorman, Mastorovich, Liberto, & Gerwick, 2010). Graduates were encouraged to acknowledge any negative thoughts associated with failure and visualize themselves as nurses, enjoying a career to which they had dedicated the last 4 years in preparation. They were also reminded that strong performance on their practice examinations was an excellent indicator that they were ready to test (Lutter, Thompson, & Condon, 2017; Poorman et al., 2010).
In line with these cognitive behavioral interventions (Poorman et al., 2010), the TRC encouraged graduates to commit to a structured preparation plan 2 weeks prior to their scheduled test date. This included completing a 265-question comprehensive Qbank examination to ensure they were prepared in the event they received the maximum number of questions on their NCLEX-RN and in the week prior, completing daily 75-question Qbank examinations with scheduled breaks. Students were also urged to take a simulated drive to the testing center, locate parking, and review the information from Pearson VUE to avoid any last-minute anxiety over these details. On their actual test date, students were encouraged to eat a healthy breakfast, dress comfortably, and entertain only positive thoughts related to NCLEX-RN success.
Graduates often shared anxiety about revealing their actual test date with friends and family members. This put an added layer of stress on them to perform; however, they were often willing to share this date with the TRC because they needed to know she supported that they were ready to test. Graduates would often communicate with the TRC via text message or telephone call the night before the examination, and the TRC would share words of encouragement and many times a prayer as well. Research has demonstrated that prayer can often lead to increased confidence, serving to minimize stress (Shores, 2010). As a faith-based university, this was a strategy to which students had become accustomed. The personalized coaching done by the TRC fostered respect for the life challenges faced by many of the program's graduates and for their cultural beliefs and values. For some students, seeking help was not something they were comfortable doing, but they came around to actively seeking help and support from the TRC. This trusting relationship was deemed as important for most students, but particularly important for the ethnically diverse students for whom English is not their native language. Non-native speakers are typically disadvantaged in achieving success as first-time licensure test takers (Kaddoura, Flint, Van Dyke, Yang, & Chiang, 2017).
For graduates whose scores indicated they were not yet adequately prepared, the TRC would recommend that they change their testing appointment sometimes by just a few days. This strategy was not something graduates would have usually done on their own, but they began to use this extra time on focused strategies to increase content knowledge.