Schools of nursing are charged with educating the next generation of nurses who demonstrate the knowledge and clinical reasoning skills to become licensed and safe practitioners in the increasingly complex health care system. First-time National Council Licensure Exam (NCLEX-RN®) success is a key measurement that holds schools of nursing accountable for strong preparation of their graduates. High failure rates may create a perception of lack of commitment to the ethical responsibility schools of nursing share for student success.
The every-three-year adjustment of the NCLEX test plan conducted by the National Council of State Boards of Nursing (NCSBN) presents a difficult challenge in achieving benchmark goals. Since 2001, national NCLEX first-time pass rates have declined during the first year after this adjustment and rebounded within three years. In 2013, a significant change in the passing standard, up one logit, was implemented by the NCSBN (2017), and nursing schools across the country were concerned about the potential for increased failures (Lavin & Rosario-Sim, 2013).
Recognizing this and concerned about a decline in their school’s 2010 pass rate to 74.75 percent, the authors created an individualized NCLEX study process. The process, known as the Kaplan Learning Integrated Course (KLIC), is based on the integrated testing and content review product used in the authors’ institution. Its purpose is to achieve NCLEX pass rates equal to or greater than the national average. This article describes the evolution of this process, which has resulted in first-time pass rates from 5.41 percent to 11.5 percent above the national bachelor of science in nursing NCLEX average for four consecutive years. Institutional review board approval was sought for this retrospective review and granted as an exempt study through the authors’ institution.
STRATEGIES FOR IMPROVEMENT
Anticipating the increase of one logit to the 2013 passing standard, the authors conducted a literature review to explore characteristics of students who were at risk for NCLEX failure. Factors such as English as a second language (ESL; Hansen & Beaver, 2012; Woo, Wendt, & Liu, 2009); lag time, defined as a delay in sitting for the exam after completing the nursing program (Eich & O’Neill, 2007; Stone & Woodberry, 2006; Woo et al., 2009); course failure, defined as out-of-sequence (OOS) students (Frith, Sewell, & Clark, 2005; Pennington & Spurlock, 2010); and low scores on content readiness integrated testing (Sanders & Irwin, 2014) were all found to contribute to low first-time pass rates.
Five major themes of interventional strategies that demonstrate positive outcomes on NCLEX success were evident throughout the literature search: 1) use of nationally recognized standardized testing, 2) use of a review course format, 3) anxiety control, 4) remediation, and 5) faculty mentoring. Hyland’s (2012) search of five major databases for the period 2001 to 2010 looked at specific interventions and outcomes on NCLEX success. Use of nationally recognized standardized testing and use of a review course format both showed merit in positively affecting NCLEX success. Carr (2011) incorporated a standardized testing program and the development of an NCLEX-integrated clinical concepts course during the last semester, focusing on areas of content review, test-taking strategies and practice, and support for anxiety and other psychological issues. Positive results on NCLEX pass rates occurred after a trial-and-error period of refining the strategies. Serembus (2016) outlined a continuous improvement plan approach that includes strategies incorporated from admission to progression to graduation that could lead to NCLEX success. Mager, Beauvais, and Kazer (2017) presented a 10-step action plan that focused on outcomes, curriculum, and grading practices for NCLEX preparation.
Culleiton (2009) focused on the concept of remediation as an intervention to assist students in passing NCLEX. Four common themes of remediation were identified: identification of students at-risk for failure, comprehensive examinations, remediation strategies, and evaluation methods. Pennington and Spurlock’s (2010) systematic review looked at the evidence supporting remediation as an intervention to improve NCLEX pass rates. These studies were mostly descriptive program evaluation reports, and more rigorous scientific inquiry of interventions to improve NCLEX pass rates is needed.
Corrigan-Magaldi, Colalillo, and Molloy (2014), in their work with a community college program, found faculty mentoring to be an essential component in guiding students to NCLEX success. Various communication strategies, teaching-learning strategies, and frequent student contact and encouragement during their last semester of this community college program were utilized with 11 at-risk students. Carrick (2011) suggested that personal problems or other external factors may negatively influence the postgraduation study period and recommended continuing contact with students as an effective strategy to impact NCLEX preparation.
KLIC OVERVIEW AND PROCESS
The purpose of KLIC is to guide students to become active and proactive with the NCLEX preparation process and products. Understanding the standardized testing resources available and how to utilize them is key to successful preparation. Consistent with the studies by Corrigan et al. (2014) and Carrick (2011), faculty mentors with knowledge of NCLEX and support strategies are another critical component in mentoring students for success. Knowing the individual learning needs of students allows faculty mentors to best support and guide individualized student study plans. As a result, test-taking strategies and practice questions, as well as support for anxiety and other psychological issues, were incorporated into KLIC.
KLIC is a hybrid pedagogy of synchronous and asynchronous learning centralized into the electronic management learning system of the university. Components include Web links to the NCLEX prep resources available through the integrated product, the NCSBN, and the Virginia State Board of Nursing. The synchronous components of the program include live classes explaining the basic tenets of NCLEX. This allows for an understanding of the NCLEX exam, test-taking strategies, study strategies, and resources available for evaluation and analysis of progress. Asynchronous learning was achieved through the use of the selected online resources available through the integrated product.
Beginning of Last Semester Senior Year
An introductory class focuses students on the tenets of the NCLEX preparation process and resources available while exposing them to the NCLEX test plan. Introduction of the Decision Tree is reviewed as a strategy for clinical reasoning (Irwin et al., 2016). This strategy incorporates the concepts of the nursing process along with principles of prioritization in making safe clinical decisions.
A 180-question standardized assessment test is administered the first week of school. Analysis of the results is used to guide students in identification of individual areas of content strength and weakness within the context of the NCLEX test plan. Review of relevant information related to each question, a component of the commercial NCLEX preparation product, includes a general overview, essential nursing care, and background for nursing care (Kaplan, Inc., 2017). Students are asked to review this material and write out three self-selected concepts to reinforce content accuracy.
Completion of three initial content-related tests provided by the test preparation company serves as a further progression into content review and is required prior to student placement in the final clinical practicum. Remediation of content deficits is initiated to refresh and review significant content required of students to apply to the application and analysis questions needed to pass NCLEX.
Faculty identified at-risk students based on the following criteria: OOS, ESL, and achievement of less than the 55th percentile rank on the assessment test. At-risk students are invited to meet with faculty to enhance further understanding of their individual preparation needs.
Students complete a different standardized 180-question diagnostic test to evaluate progress in knowledge and development of critical thinking as applied to testing. This test is meant to be instructive in nature and used as a formative tool, not an exit exam and not as a punitive measure. Students analyze this test through a written standardized test review guide to develop an individual remediation plan.
An in-person or live online class is conducted to demonstrate application of the Decision Tree to selected practice questions. Practical tips for NCLEX testing, including registration, barriers to receiving the Authorization to Test, and obstacles for focused preparation are presented. Application and analysis questions are assigned during the clinical practicum course. This assignment includes analysis and remediation of results.
End of Semester and Postgraduation
Attendance at the NCLEX review course, scheduled for the final week of the semester, is mandatory. Students develop a study plan for postgraduation preparation, and faculty provide weekly or more frequent follow-up with students via email, live online, or video conference until success on NCLEX is achieved. Review and recommendations of study plans are adjusted to meet the individual student’s progress. Students are guided through the process of achieving content competency and how to use content to make safe patient care decisions. Individualized study plans are discussed with students who are struggling with meeting target scores on testing.
External factors that could delay or negatively impact sitting for NCLEX are reviewed. Such factors include anxiety, life situations, work, family, and/or financial demands (Carrick, 2011; McDowell, 2008). Students are encouraged to test within 26 to 33 days of graduation (Eich & O’Neill, 2007); (Stone &Woodberry, 2006; Woo et al., 2009), and faculty evaluate their scores on practice tests to guide students in deciding if they are ready to test. If they are found to be unprepared for the test, faculty continue to provide guidance until target scores are met. The final decision to test rests with the student.
RESULTS AND DISCUSSION
KLIC was implemented with all students graduating in spring 2013. Seven at-risk students who were either OOS or ESL were invited to participate in an individual study progress analysis. Five of the seven students in this pilot process were successful in passing NCLEX on the first attempt. The overall class first-time success rate was 91.38 percent for this 2013 cohort of students.
The identification of at-risk students was further expanded with the fall 2013 cohort to include students who achieved less than the 55th percentile on the assessment test. Although focus on at-risk students was a priority, all students in each cohort were provided access to individual faculty support and guidance. Cumulative pass rates reflect a 95 percent success for all first-time test-takers from the authors’ institution. Although the 5 percent who failed were identified as at risk, they represent only 8.3 percent of the total at-risk population.
Since KLIC was introduced, graduates have achieved a sustained pass rate of 5.41 percent to 11.5 percent greater than the national BSN average for four consecutive years. This preparation process incorporates the tools for students to provide concurrent review of the entire curriculum content and integrated threads. The benchmark for NCLEX pass rates established by the Program, Quality and Evaluation Committee of the school of nursing (SON) have been met consistently after the implementation of KLIC.
Anecdotally, students have reported the program provides a mechanism to manage the testing environment. They feel empowered and confident in utilizing both content knowledge and critical thinking, key elements of success on first-time NCLEX passage. The sustained success of KLIC has filtered down to subsequent graduates who report they are now motivated and challenged to maintain or exceed previous semesters’ pass rates.
The design of this NCLEX prep process reflects a promising and powerful model for first-time NCLEX success. It allows for concurrent review of the SON curricular alignment with the NCLEX blueprint and can be adapted to any curriculum and adjusted to meet the particular needs of any nursing program. Schools may identify different criteria for high-risk students and/or barriers for their unique student body.
It is essential for SONs to designate one or more faculty members who are NCLEX champions to stay current on the changes in the NCLEX exam and knowledgeable of the resources used to guide students to NCLEX success. The authors recognize their student body as a homogenous group. More study is warranted with cohorts of varying demographics and needs. Collaboration with other schools of nursing to replicate and validate this process has been initiated to provide greater evidence of its effectiveness with a less homogenous group of students.
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