For most nurse managers and their RN staff members, taking the national licensure exam is an anticlimactic end to a multiple-month lead up. Nonetheless, passing the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) is a high-stakes exercise for graduates and the programs that train them. The exam has changed over the years, perhaps most dramatically with the switch from a paper-and-pencil format to a computerized adaptive testing model nearly 25 years ago. However, its goal has remained steady: to assess new graduates' readiness to begin practicing nursing safely.
There's a great deal of literature about the NCLEX-RN aimed at students interested in the nuts-and-bolts of the exam. In fact, materials are available for free or at low cost from the National Council of State Boards of Nursing website (https://www.ncsbn.org). In this article, we'll review the exam as it relates to you as a nurse manager in terms of how it's constructed and delivered, what results mean, and how and why meeting standards for pass rates is affecting the nursing programs supplying the students and new graduates coming to your units. (See Tips for managers.)
Computerized adaptive testing
The NCLEX-RN isn't a traditional test in a number of ways; it's very different from any test that most applicants have taken in their educational histories and the theory behind it puzzles many. Rather than having all test takers attempt the same questions presented in the same order and then calculating the proportion of questions that were correctly answered, in computerized adaptive testing, a software program draws from a large pool of questions whose difficulty has been calculated (the program knows what percentage of all test takers answer each question correctly). By asking carefully chosen questions from the pool based on how well the test taker has done on previous questions, the computer attempts to use as few questions as possible to determine whether a test taker meets the predetermined competency level as shown by consistently answering questions at a certain difficulty level. Each applicant answers a different set of questions and a different number of questions. Some individuals complete 75 questions and others over 200; the program asks only as many questions as are needed to make a valid pass or fail decision. This is an efficient method of measuring the level of knowledge suggestive of the ability to begin practicing safely.
Although performance feedback is provided to test takers who've failed the exam and to nursing programs, no scores are reported per se. This is because scores wouldn't be relevant to whether a prospective nurse meets the predetermined standard—the number of questions answered correctly is less important than whether a critical mass of those questions are at a level of difficulty suggesting that the candidate has a safe knowledge level.
As of this writing, about 160,000 American-educated nurses take the NCLEX-RN for the first time each year. Because ensuring that those who pass have a safe level of knowledge is the primary concern, with fairness to all test takers, this is a very carefully constructed exam. Surveys of the knowledge and skills newly licensed nurses use in their work are done every few years. The questions are developed and reviewed in a rigorous process by educators and supervisors who work with nurses in the early years of their careers, and then undergo extensive pretesting. Over time, the questions have come to include alternative formats for which test takers are asked to calculate drug dosages, place the steps of a procedure in the correct order, or identify clinically important anatomic regions or equipment parts, as well as questions in a conventional “choose the best response” format. The content isn't primarily guided by textbook content; the exam is based on evidence-based best practice used by entry-level clinicians, which, of course, changes over time.
First-time test takers and pass rates
A variety of institutions serving a range of communities offer nursing education programs. Almost as long as there have been nursing education programs, there have been concerns about program content and quality variations across programs that a common national licensure exam for graduates was intended to address. Today, many, if not all, state boards publish the success rates of first-time test takers as a quality indicator of nursing programs, and students and their families look at these numbers closely before committing to a program. Furthermore, most state boards may ask for documentation from programs with low pass rates and sometimes require that program officials make changes until pass rates come up to an acceptable level.
Not surprisingly, nursing schools have responded to the imperative for their graduates to pass a challenging exam in a variety of ways, such as changing admission processes, increasing student testing throughout their nursing education, and requiring certain scores on comprehensive exit exams aimed at predicting passing the NCLEX-RN before officials award diplomas and/or sign off on certificates of program completion. Educators have been cautioned to maintain entry standards for their programs and ensure that grade inflation is kept in check. They've been further urged to make sure that tests in their programs assess problem solving and higher-level thinking rather than mere recognition of correct answers or superficial understanding of content. Many instructors have begun to integrate alternative test question formats into their quizzes, tests, and exams to provide a preview of the challenging types of NCLEX-RN questions.
Many nursing programs have also introduced more detailed and stringent criteria for the circumstances under which students are asked to leave programs after they've failed theory or clinical courses. The main purpose of all of these practices in nursing schools is to ensure that students with a low likelihood of finishing programs and becoming licensed avoid wasting their money after a pattern of failure has become clear, but, of course, these policies are also intended to avoid low NCLEX-RN pass rates. However, the fear is that overly harsh policies may steer away people with key talents and perspectives whose paths may be more challenging but who could ultimately serve their communities well, especially in nursing, where we value having a diverse workforce reflective of the patient populations we serve. The challenge is finding the right mix of standards and flexibility.
There's at least one other issue to be considered regarding student success on the NCLEX-RN as it relates to program quality—and it comes back to the entry-into-practice issue. Associate degree programs aim to produce practice-ready generalist nurses who can pursue more education if desired; baccalaureate programs attempt to develop a broader knowledge and cognitive skill base as preparation not only for careers in direct care, but also a range of leadership roles. Although there's overlap between associate, diploma, and baccalaureate programs in terms of content, baccalaureate-specific content isn't tested on the NCLEX-RN. This ensures that a common base of knowledge and judgment is held by those entering RN practice regardless of the type of program in which they studied, but the base is a floor, not a ceiling. Students in a variety of programs may come to nursing school with the assumption that they'll be taught everything they need to know to pass the licensure exam, but it's more realistic to expect that the majority of content they need will be covered and they'll have to fill in small coverage gaps in the weeks leading up to the test.
There are very real questions about whether the NCLEX-RN—designed as a check on student outcomes and skills from a regulatory perspective—has ultimately become a driver of program content beyond what's helpful and in ways that were never intended. This is a version of the “teaching to the test” problem seen in elementary and high school testing; however, it may be more of a problem with student expectations and program policies than with the test itself or the way regulatory bodies use it in awarding licenses.
A rite of passage
Many of us who took our licensure exam in the “good old days” of paper-and-pencil testing are now deep into our nursing careers; some of us may have taken the NCLEX-RN in the computerized adaptive testing format that closely resembles the version new graduates are now taking. Either way, the test is seen as a rite of passage. NCLEX-RN success is part of a larger pattern of individual careers and the evolution of the profession.
Tips for managers
- Encourage new graduates to file their licensure paperwork with the state board to become test-eligible as quickly as possible after graduation and to take the exam when they feel ready, but to set a test date quickly after getting cleared to test.
- Help students understand that the NCLEX-RN is a by-the-book test; trick questions are kept to a minimum. Correct answers are based on practice standards and guidelines, and are reviewed regularly.
- Try not to over- or underplay the difficulty or importance of the test. The NCLEX-RN is a test of safety to begin practice; after the student has passed, it won't matter whether he or she only answered the minimum number of questions to pass. At the same time, it's a challenging exam that covers a wide range of content and requires thoughtful preparation.
- Make sure that new graduates you supervise or mentor understand that there are a variety of ways to prepare for the test (such as in-person courses, books, or online courses and materials), but extensive practice answering questions that emphasize content application is critical. New graduates are commonly advised to practice with at least 3,000 NCLEX-RN style questions.
- Failing the NCLEX-RN is disheartening and costly, but need not be the end of the world, especially if students have completed fundamentally sound programs. However, because repeat testers tend to perform poorly on retakes, especially after sitting a second time, those who've failed the NCLEX-RN should consult their professors, educational program administrators, and/or staff education specialists at their institutions to make sure that they understand what went wrong the first time and are on a track to be successful.
- Understand that if a program's graduates are performing poorly on the NCLEX-RN, the causes may lie with the program, the students, or both. When NCLEX-RN failures are affecting staff recruitment and onboarding, there may be cause for a clinical agency and its leaders to offer assistance and support. However, first-time pass rates are only one program outcome; a single-minded focus on maintaining close-to-perfect pass rates may push out important and meaningful content, and may lead to the creation of program policies that cause needless stress for instructors and students.