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Quantitative Research

Diagnostic readiness tests

Preparing nurse practitioner students for national certification examinations

Coppa, Denise PhD, FNP-C, FAANP (Project Director, Interim Associate Dean and Associate Professor)1; Barcelos Winchester, Suzy MA (Project Manager and Research Associate)1

Author Information
Journal of the American Association of Nurse Practitioners: January 2020 - Volume 32 - Issue 1 - p 52-59
doi: 10.1097/JXX.0000000000000191
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Abstract

In response to critical workforce demands for nurse practitioners (NPs) as primary health care (PHC) providers, NP faculty are challenged to offer the core didactic curriculum and clinical experiences in PHC. Current challenges that accredited NP programs face include the depth and breadth of didactic knowledge necessary to prepare students to perform in clinical placements and to assist students to assimilate into the NP role after graduation. To meet these challenges, Colleges of Nursing have leveraged federal dollars to establish academic–clinical partnerships (ACPs) as a means through which to enhance the practice opportunities of NP students. Emanating from the inception of the Patient Protection and Affordable Care Act, these ACPs have created a matrix of demonstration projects across the country that have enhanced the education of NP students and created value-based health care models that have contributed to better patient outcomes, decreased hospital and emergency department admissions while demonstrating a decrease in health care costs (Coppa, Barcelos Winchester, & Roberts, 2018).

Academic–clinical partnerships facilitate the integration of clinical faculty into community health centers to enhance the number and quality of NP student clinical placements. The ACPs potentially remove a barrier that exists in graduate nursing education to provide adequate numbers of clinical placements. The ACPs are mutually beneficial to the clinical agency and academic institution because they advance the interests of practice, education, and research. Most notably, ACPs contribute to innovative educational designs, student articulation into new practice roles, and positive workforce development (Beal, 2012). They have demonstrated sustained learning experiences for students and improvements in patient outcomes, especially when the relationship between agencies is formal and structured (Beal, 2012; Smith, Lutenbacher, & McClure, 2015). They allow for mentorship between the clinical faculty, preceptors, and students. Mentorship is accepted as a means to facilitate the assimilation into the advanced practice nursing role for NP students (Hill & Sawatzky, 2011). However, successful transitioning to the NP role requires more than the attainment of a prescribed number of clinical hours. Challenges that lead to anxiety can affect the transition experience (Barnes, 2015; Leflore & Thomas, 2016).

Nurse practitioner faculties are challenged to offer a curricula that balance delivery of didactic knowledge with supervised clinical practice to prepare graduates for the complexities of the health care system. Nurse practitioner graduates must apply knowledge they attain in NP programs to postgraduation certification examinations. Between graduation and employment as an NP, there is an expressed sense of uncertainty and worry around obstacles to obtaining a license, such as successful completion of the certification examinations (Brown & Olshansky, 1997). Nurse practitioner programs can help to remove a significant source of anxiety and contribute to a more smooth transition from the registered nurse (RN) to NP role by offering diagnostic readiness tests (DRTs) as a requirement prior to graduation.

Approximately 86% of the 23,000 NP students who graduate every year specialize in PHC (American Association of Nurse Practitioners, 2018), and 76–82% of the students pass on the first attempt. Students who take certification examinations more than once take longer to become licensed and, in effect, longer to enter the workforce. Preparation for postgraduate testing integrated within the program can facilitate workforce entry if NP graduates pass these examinations on their first attempts.

Innovative educational tools are necessary to ease the uncertainty and stress that NP students experience to graduate and to access the specific knowledge and self-confidence to pass these certification examinations (Barnes, 2015). One aspect that contributes to innovation and assures success in passing certification examinations is the standardized assessment of students' didactic and clinical knowledge prior to graduation (Giddens et al., 2016). However, a gap exists in the educational literature that reports data-driven measurement in the usefulness of incorporating DRTs into NP courses. Therefore, the purpose of this report was to examine DRT scores for NP students prior to graduation and the impact that ACP placements have on DRT performance.

Methods

Participants

Participants included PHC NP students in the final semester of the Family Nurse Practitioner (FNP) and Adult Gerontological Nurse Practitioner (AGNP) programs at the University of Rhode Island from Spring 2016 to Fall 2017. In total, there were 99 active NP students (84 FNP and 15 AGNP). This report included a convenience sample of all NP students during the final semester of their programs.

Funded by a Health Resources and Services Administration grant, both ACPs were community health centers and Federally Qualified Health Center organizations serving four health professions shortage area communities. The ACPs provide medical, dental, and behavioral health care for 91,000 medically underserved patients within clinics, homeless shelters, schools, and home settings. Students were randomly assigned to clinical placements in ACPs or non-ACPs. This was a quasi-experimental, prospective, one-group, prestudy/poststudy design.

Procedure

Nurse practitioner students were assigned to an ACP or non-ACP clinical setting during 14-week semesters from Spring 2016 to Fall 2017. Nurse practitioner students completed the Barkley & Associates, Inc. Diagnostic Readiness Test (DRT; 2016) during the Fall 2016 and Fall 2017 semesters prior to graduation. The DRT is an NP licensing practice examination that prepares students for the postgraduation NP certification examination. Barkley & Associates, Inc. provided a secured link for students to access and complete the DRT examination with a 100-minute time allotment. Pretests were completed in September 2016 and September 2017, and posttests were completed in December 2016 and December 2017. Students were allowed to review their performance in a 45-minute period immediately after completion of the DRT. Data privacy and confidentiality assurances were provided by Barkley & Associates, Inc. The project was approved by the university Institutional Review Board.

Measures

Demographics

Nurse practitioner students recorded demographic information (i.e., gender identification, age, ethnicity/race, NP specialty [i.e., FNP, AGNP], and type of clinical placement [ACP, non-ACP]) at the beginning of each semester into an electronic student tracking database system (i.e., Typhon Group, LLC, 1995).

Clinical sites

Clinical site information (i.e., name of clinical site, type of clinical site) was recorded in the database. All clinical sites enter into educational agreements prior to students beginning clinical placements.

Diagnostic readiness test

Student workforce readiness was assessed with the Barkley & Associates, Inc., Diagnostic Readiness Test prior to graduation in September 2016 and September 2017 (pretest) and in December 2016 and December 2017 (posttest). The DRT consists of 100 items for both FNP and AGNP tests and measures student preparedness for certification examinations (Barkley & Associates, Inc., 2016).

The FNP DRT consisted of 26 individual health care categories, including adolescent, cardiovascular, contraceptive, dermatological, ears/eyes/nose/throat, endocrine, gastroenterological, genetics, genitourinary, growth/development, gynecology/men's health, hematologic, immunization, infant health, integumentary, issues trends, lower respiratory, musculoskeletal, neurologic, obstetrics and pregnancy, prenatal, psychosocial, respiratory, school age, sexually transmitted diseases, and toddler/preschool. From those categories, a total overall score and six domain scores (assessment, diagnosis, laboratory and diagnostics, management and treatment, pharmacology, and professional practice) for FNP students were derived (Barkley & Associates, Inc., 2016).

The AGNP DRT consisted of 15 individual health care categories, including cardiovascular, contraceptive, ears/eyes/nose/throat, endocrine, gastroenterological, gynecology/men's health, hematologic, integumentary, lower respiratory, musculoskeletal, neurologic, obstetrics and pregnancy, practice issues, psychosocial, and sexually transmitted diseases. A total overall score and five domain scores (assessment, diagnosis, laboratory and diagnostics, management and treatment, and pharmacology) for AGNP students were derived (Barkley & Associates, Inc., 2016).

The DRT provided postexamination results, areas of student strengths and weaknesses, and remediation suggestions. The DRT test scores ranged from 0 to 100 with a mean of 50 (SD = 10). The DRT reports categorical cutoff scores, with scores ≤59 indicating deficient performance, scores 60–69 = good performance, scores 70–79 = strong performance, and scores ≥80 = excellent performance (Barkley & Associates, Inc., 2016).

Professional certification examination

Students reported their pass rates (pass/fail) on the professional NP certification examination in a standard postgraduation survey (American Association of Nurse Practitioners Certification Board, 2018).

Analytic strategy

Overall and domain pretest and posttest scores (dependent outcome scores) for NP students (FNP and AGNP students combined) were examined using the nonparametric Wilcoxon signed ranks test because overall and domain scores violated assumptions of normality and homogeneity of variance and transformation did not improve normality. Categorical outcome variables were calculated based on the DRT cutoffs with scores ≤59 indicating deficient performance, scores 60–69 = good performance, scores 70–79 = strong performance, and scores ≥80 = excellent performance on the overall and domain scores. Chi-square analyses examined associations on overall and domain DRT categorical outcomes for all NP students. Next, a chi-square test of association was used to examine the association between NP student status (FNP and AGNP) and DRT categorical scores (excellent, strong, good, and deficient).

A comparison between NP students placed at an ACP (n = 18) clinical site and non-ACP (n = 8) clinical site was conducted. To evaluate comparisons between ACP versus non-ACP settings, a change score was calculated for the Barkley DRT overall score and domain scores (assessment, diagnosis, laboratory and diagnostics, management and treatment, pharmacology, and professional practice). Some change scores resulted in a negative integer. This was addressed by adding a constant to all change score outcomes: (maximum score + 1) − X. The change score for Barkley DRT overall and domain scores violated the assumption of normality, although homogeneity of variance was adequate. A square root transformation was conducted, but yielded a non-normal distribution. Thus, the nonparametric Mann–Whitney U test was used to analyze differences between students placed in an ACP versus non-ACP clinical rotation on the square root transformed change scores for Barkley DRT overall and domain scores. Analyses were conducted using IBM SPSS Statistics version 23 (IBM Corp., Armonk, NY).

Results

Descriptive analyses

Student demographics

Twenty-six students completed the DRTs. Seventy-three percent (n = 19) were FNP students and 27% (n = 7) were AGNP students. Ninety percent (n = 17) of FNP students were female and 10% (n = 2) were male; 86% (n = 6) of AGNP students were female and 14% (n = 1) were male. Sixty-nine percent (n = 18) of students were White, 27% (n = 7) Black or African American, and 4% (n = 1) Asian. None were Hispanic/Latino. Eighty-four percent (n = 16) of FNP students were White, 11% (n = 2) were Black or African American, and 5% (n = 1) were Asian. For AGNP students, 71% (n = 5) were Black or African American and 29% (n = 2) were White.

Seventy-eight percent of NP students (n = 20) were in the master's tract, 11% (n = 3) doctor of nursing practice (DNP), and 11% (n = 3) post-master's certificate. The degree by gender identification breakdown was as follows: 90% (n = 18) of master's prepared candidates were female and 10% (n = 2) were male; 100% (n = 3) DNP were female and 0% were male; and 67% (n = 2) post-master's certificate candidates were female and 33% (n = 1) were male.

Main analyses

Twenty-six NP students completed the DRTs (18 students in 2016 and 8 students in 2017). Eighteen NP students were placed in an ACP clinical rotation and 8 NP students were placed in a non-ACP clinical site. Ninety-two percent (n = 24) of students reported their pass rate (pass/fail) on the NP professional certification examination, with 100% pass rate on first attempt.

Diagnostic readiness test overall performance

The overall DRT scores for the NP students, as a group, were significant and improved over time. The Wilcoxon signed ranks test showed that the posttest scores were significantly higher than pretest scores, with the median for the post-test overall score significantly higher (median = 67.5) than the pretest overall scores (median = 60.0), z = −3.9, p < .0001.

The Mann–Whitney U test revealed no differences between students placed in an ACP clinical setting compared with those placed in a non-ACP clinical site on the overall DRT change score (posttest–pretest). Specifically, students placed in an ACP (median = 6.2) did not differ from students placed in a non-ACP clinical site (median = 5.7) on the overall DRT performance, U = 31.5, z = −1.8, p > .05.

Diagnostic readiness test domain scores

Nurse practitioner students scored significantly higher on 4 DRT posttest domains scores (assessment median = 65.5; diagnosis median = 74.0; management and treatment median = 69.5; and pharmacology median = 67.0) compared with pretest scores (assessment median = 58.0; diagnosis median = 62.0; management and treatment median = 60.0; and pharmacology median = 67.0), z = −2.3, p < .02; z = −3.0, p < .002; z = −3.3, p < .001; and z = −2.2, p < .03, respectively. There were no differences between pretest and posttest scores on the laboratory and diagnostics (pretest median = 64.0, posttest median = 70.0) and professional practice (pretest median = 50.0, posttest median = 50.0) domains, z = −1.2, p > .05 and z = −0.5, p > .05, respectively.

The Mann–Whitney U test reported no differences between students placed in an ACP setting compared with a non-ACP clinical setting on the DRT domain change scores: assessment (pretest median = 6.0, posttest median = 5.8), diagnosis (pretest median = 7.4, posttest median = 7.6), laboratory and diagnostics (pretest median = 7.9, posttest median = 7.6), management and treatment (pretest median = 5.0, posttest median = 3.4), pharmacology (pretest median = 4.4, posttest median = 5.9), and professional practice (pretest median = 7.1, posttest median = 5.9), U = 47.5, z = −0.76, p > .05; U = 59.0, z = −0.32, p > .05; U = 48.0, z = −0.73, p > .05; U = 32.0, z = −1.8, p > .05; U = 43.0, z = −1.1, p > .05; and U = 28.0, z = −0.21, p > .05, respectively.

Categorical analysis

Diagnostic readiness test overall performance

There were no differences between FNP and AGNP students on overall DRT performance, χ2(3) = 3.3, p > .05. Eighty-nine percent (n = 23) of all NP students scored within the categories of excellent, strong, and good performance on the overall posttest DRT score and 11% (n = 3) had deficient overall performance (Figure 1). The majority FNP students (84%, n = 16) scored within the good to excellent categories on the overall DRT posttest with 16% (n = 3) deficient performance. All AGNP students (100%, n = 7) scored within the good to strong categories on the overall DRT posttest (Figure 2).

Figure 1
Figure 1:
Overall nurse practitioner student performance on diagnostic readiness test.
Figure 2
Figure 2:
Comparison of family nurse practitioner and AGNP student performance on diagnostic readiness test. AGNP = Adult Gerontological Nurse Practitioner.

There were no differences between students placed in an ACP compared with a non-ACP clinical setting on overall DRT performance, χ2(3) = 4.6, p > .05. Approximately 90% of students placed in an ACP (n = 16, 89%) scored in the top 3 ranks (i.e., excellent, strong, and good combined) compared with 11% (n = 2) with deficient overall performance (Figure 3). Eighty-eight percent (n = 7) of students placed in non-ACP settings had good to strong overall performance, whereas 12% (n = 1) had deficient overall performance on the DRT posttest.

Figure 3
Figure 3:
Academic–clinical partnership and non-ACP performance on diagnostic readiness test. ACP = academic–clinical partnership.

DRT domain scores

Nurse practitioner students performed comparably across all DRT domains. Eight-one percent (n = 21) scored in the top 3 ranks (i.e., excellent, strong, and good combined) in the assessment domain compared with 19% (n = 5) with deficient performance (Figure 1). For the diagnosis domain, 81% (n = 21) performed in the good to excellent categories and 19% (n = 5) had deficient performance. Seventy-three percent (n = 19) scored in the excellent and strong ranks on the laboratory and diagnostics domain and 27% (n = 7) had deficient performance on this domain. For the management and treatment domain, 85% of NP students (n = 22) had good to excellent performance and 15% (n = 4) had deficient performance. Ninety-two percent (n = 24) of NP students scored with the strong to excellent categories on the pharmacology domain and 8% (n = 2) had deficient performance. Finally, 37% of students (n = 7) scored in the excellent and strong ranks and 63% (n = 12) had deficient performance (FNP students only; Figure 1).

Family nurse practitioner student performance on diagnostic readiness test domains

Seventy-nine percent of FNP students (n = 15) performed well above average (categorical ranges of excellent, strong, and good combined) in the assessment domain, whereas 21% (n = 4) had deficient performance (Figure 2). Eighty-four percent (n = 16) scored in the top 3 ranks (i.e., excellent, strong, and good combined) in the diagnosis domain compared with 16% (n = 3) with deficient performance. Sixty-eight percent (n = 13) performed in the good to excellent categories on the laboratory and diagnostics domain with 32% (n = 6) scoring in the deficient category. For the management and treatment domain, 89% (n = 17) of the FNP students scored in top 3 ranks compared with 11% (n = 2) with deficient performance. Ninety-five percent of the FNP students scored in the excellent (n = 6) and good (n = 12) categories on the pharmacology domain with 5% (n = 1) in the deficient category. For professional practice, 37% of the FNP students (n = 7) scored in the excellent and strong ranks, whereas 63% (n = 12) had deficient performance (Figure 2).

Adult gerontological nurse practitioner student performance on diagnostic readiness test domains

For AGNP students, 86% (n = 6) had good performance on the assessment, whereas 14% (n = 1) had deficient performance (Figure 2). Seventy-one percent of AGNP students (n = 5) performed well above average (categorical ranges of excellent, strong, good combined) in the diagnosis domain, whereas 29% (n = 2) had deficient performance. For the laboratory and diagnostics domain, 86% (n = 6) of AGNP students scored in the strong and good categories with 14% (n = 1) in the deficient category. Seventy-one percent (n = 5) of AGNP students had good to strong performance on the management and treatment domain compared with 29% (n = 2) with deficient performance. Eighty-six percent (n = 6) scored in the excellent and good ranks for pharmacology compared with 14% (n = 1) with deficient performance (see Figure 2).

Academic–clinical partnership and non–academic–clinical partnership performance on diagnostic readiness test domains

There were no differences between students placed in an ACP compared with a non-ACP setting on the DRT domains: assessment χ2(3) = 2.2, p > .05; diagnosis χ2(3) = 5.6, p > .05; laboratory and diagnostics χ2(3) = 0.78, p > .05; management and treatment χ2(3) = 2.66, p > .05; pharmacology χ2(3) = 0.50, p > .05; and professional practice χ2(3) = 0.64, p > .05.

Of the students placed in ACP clinical settings, 78% (n = 14) scored in the top 3 ranks on the assessment domain and 22% (n = 4) had deficient performance (Figure 3). Seventy-eight percent (n = 14) performed in the good to excellent categories on the diagnosis domain compared with 22% (n = 4) with deficient performance. Seventy-two percent of students placed in an ACP (n = 14) scored in the top 3 ranks on the laboratory and diagnostics domain and 28% (n = 5) had deficient performance. For the management and treatment domain, 78% (n = 14) scored in the good to excellent range, with 22% (n = 4) scoring in the deficient category. The majority of students in ACP settings (94%) scored in the excellent (n = 6) and good (n = 11) categories on the pharmacology domain and 6% (n = 1) had deficient performance. Thirty-nine percent had excellent (n = 4) and good (n = 1) performance on the professional practice domain and 61% (n = 8) had deficient performance (Figure 3).

For students placed in non-ACP clinical settings, 13% (n = 1) had excellent performance and 75% (n = 6) had good performance on both assessment and diagnosis domains, with 12% (n = 1) scoring in the deficient category (Figure 3). Seventy-five percent (n = 6) scored in the top 3 ranks on the laboratory and diagnostics domain compared with 25% (n = 2) with deficient performance. All students in non-ACP settings (n = 8, 100%) scored in the top 3 ranks of performance for the management and treatment domain. Eighty-eight percent scored in the excellent (n = 3) and good performance (n = 4) categories of the pharmacology domain compared with 12% (n = 1) with deficient performance. Thirty-four percent had excellent (n = 1) and good (n = 1) performance on the professional practice domain and 66% (n = 4) had deficient performance (Figure 3).

Discussion

A convenience sample that included 99 PHC NP students was given the opportunity to take the DRT (Barkley & Associates, Inc., 2016) at the beginning and at the conclusion of the final semester of their NP program. The student sample was taken from 2 cohorts, one that graduated in December 2016 and another that graduated in December 2017. A total of 26 NP students took the DRT. All NP students significantly improved over time on the overall DRT scores. Statistically significant improvement was noted between the beginning and end of the semester in the assessment, management and treatment, pharmacology, and diagnosis domains. There were no differences between the pretest and posttest scores in the laboratory and diagnostics and professional practice domains. The DRT includes the professional practice domain for FNP students only.

There were no differences between FNP and AGNP performance in overall DRT performance and across the DRT domains. Overall, 84% of the FNP students scored in the top 3 ranks (i.e., excellent, strong, and good combined) of the overall DRT performance. Of the AGNPs, 100% scored in the top 3 ranks. Approximately, 90% of students placed in both ACP and non-ACP settings scored in the top 3 ranks. Seventy-three percent to 92% of the NP students performed well above average (categorical ranges of excellent, strong, and good combined) on 5 of the DRT domains (assessment 81%, diagnosis 81%, laboratory and diagnostics 73%, management and treatment 85%, and pharmacology 92%). For the professional practice domain, offered only to FNP students, 37% of students had excellent and good performance scores compared with 63% scoring in the deficient category.

No statistical differences were found on the overall DRT or domain scores between students placed in ACP and non-ACP settings. However, categorically, performance in specific domains was striking. Approximately, 90% of students placed in non-ACPs performed in the excellent to good categories for the assessment and diagnosis domains compared with 78% of students in ACP settings. Students in both clinical settings performed similarly in the laboratory and diagnostics domain (72–75%). All NP students in non-ACP settings performed well above average in the management and treatment domain compared with 78% of students in ACP settings. Approximately, 95% of students in ACP settings scored well above average in the pharmacology domain compared with 63% of students in non-ACP settings. Finally, students in both clinical settings performed similarly in the professional practice domain (34–39%).

There are possible reasons for no statistical differences between students placed in ACP settings compared with non-ACP settings. First, much of the successful completion on DRT tests is based on knowledge gained in didactic courses that the NP students take concurrently with the clinical courses. Second, there was no attempt made to determine if the students taking the DRTs during their last clinical semester had been assigned to ACPs during previous semesters.

After graduation, all graduates included in this study were contacted by the author to report whether they passed their certification examinations. Ninety-two percent (n = 24) of the students passed the American Association of Nurse Practitioners certification examination on the first attempt. These results were well above the aggregate data reported by the American Association of Nurse Practitioners Certification Board that reported first-time pass rates from 2016 to 2017 graduates to be 80–86%, overall (American Association of Nurse Practitioners Certification Board, 2018).

Limitations

The significance of this study was limited by the small sample size. Therefore, it was difficult to compare subscale scores between NP specialty and clinical setting. Also, it would be informative if this was conducted as a multiprogram study to increase overall numbers of participants. It would be informative to add qualitative analysis to the study by interviewing NP students to determine their impressions of taking the examinations. In addition, comparison between DRT test scores and midterm and final examinations scores for overall student performance and between NP specialty would be useful. Finally, attempts to correlate with actual first-time pass rates on certificate examinations within a set period after graduation will add more validity to the value of administration of DRT examinations to NP students.

Conclusions

Literature suggests that the integration of a standardized approach for pregraduation testing of NP students, prior to assignment to a clinical agency, could increase clinical education performance (Giddens, et al., 2016). It would be interesting to integrate the DRT examinations during the first semester of NP programs, prior to their clinical assignments, to determine if there would be a positive impact on clinical performance and postgraduation certification examinations. Meeting the increase in the PHC workforce needs requires the graduation of clinically competent, self-confident NPs with core knowledge of the provision of direct PHC services in a variety of health care settings (Leflore & Thomas, 2016). Diagnostic readiness testing has been suggested to become included as a standardized student assessment at the outset and throughout competency-based NP programs as a means to ease the anxiety of transition from the RN to NP role (Barnes, 2015; Giddens et al., 2016). Other suggestions have been made that DRTs can act as proxy for the postgraduation certification examinations and that actively taking on-line practice tests can reduce anxiety and improve test scores (Barnes, 2015; Snooks, 2005). There is enough evidence to support the integration of DRTs to reduce RN to NP transition anxiety and increase practice self-confidence.

Acknowledgments:This project was supported by the Health Resources and Services Administration (HRSA) under grant number #D09HP28858, University of Rhode Island College of Nursing Academic Practice Partnership (Advanced Nursing Education). This information or content and conclusions are those of the authors and should not be construed as the official position or policy nor should any endorsement be inferred by HRSA or HHS or the US Government.

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Keywords:

Diagnostic readiness testing; nurse practitioner student workforce readiness; preparation for nurse practitioner certification exams

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