Nurse Educator Vol. 39, No. 6, pp. 285-289 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
A Multifaceted Progression Approach to Enhancing Student Success Leslie G. Cole, DNP, RN & Marsha H. Adams, PhD, RN, CNE, ANEF This article describes how a faculty rallied together and developed a positive progression approach to promote student success on standardized specialty and comprehensive examinations, which fosters critical thinking, clinical judgment, student self-assessment, and individualized plans of action. Specific strategies implemented are discussed. Aggregate student data related to course grades, specialty and comprehensive exit examination scores, and NCLEX pass rates support this innovative approach to student success. Keywords: exit examination; nursing students; progression testing; remediation; standardized testing; student success
A
s the nursing shortage continues to be a major healthcare concern, nursing programs are charged with the duty of increasing student retention and graduation rates and adequately preparing students for licensure. Licensure pass rates, a key benchmark for prelicensure nursing education programs, have been a popular topic in nursing education research. Nurse educators have repeatedly published literature to address low licensure pass rates.1-5 In an effort to prepare nursing students for NCLEX-RN, nursing programs have implemented total curriculum revision and the use of standardized testing and remediation programs.1 Nibert and Morrison,6 in a review of evidence-based research, suggested that the comprehensive exit examination (comprehensive standardized examination taken at the end of the nursing program prior to graduation) was ‘‘96.36% and 99.16%’’ accurate in predicting success on the licensure examination. Progression testing, the use of standardized testing in specific content areas, allows for measurement of content knowledge as students progress through nursing courses.4,6 Progression testing provides students an opportunity to experience testing that is similar to the NCLEX-RN.7 Standardized testing helps students identify areas of weakness, providing a helpful selfassessment of content and knowledge gaps.8 Santo et al4 stressed the importance of designing remedial programs based on students’ lack of knowledge in particular content areas. Nursing programs that use standardized testing as a tool to enhance student success should analyze testing reports to identify and strengthen weak areas in their nursing curriculum.
Author Affiliations: Assistant Professor (Dr Cole), Capstone College of Nursing, The University of Alabama, Tuscaloosa; Professor and Dean (Dr Adams), College of Nursing, The University of Alabama in Huntsville. The authors declare no conflicts of interest. Correspondence: Dr Cole, Box 870358, Tuscaloosa, AL 35487 ([email protected]). Accepted for publication: August 3, 2014 DOI: 10.1097/NNE.0000000000000084
Nurse Educator
After analyzing reports to determine weak content areas in their nursing program, faculty can determine if their current teaching strategies are effective in promoting knowledge retention.9 Because nursing is a practice profession that requires the application of theory in a clinical situation, nurse educators should use strategies that foster critical reasoning by engaging students in active learning processes.6 Active learning methods include case studies, discussion or debates, simulation, and role playing, among others.10 Students who appear to have knowledge gaps on nursing examinations may lack the ability to use their knowledge to practice safe and effective patient care. Because standardized and licensure examinations test the student’s ability to analyze knowledge and apply it to a patient situation, students who have poorly developed critical reasoning and clinical judgment skills will most likely perform poorly on these examinations. Lasater11 stated that thinking is not a linear process. Nurse educators, who understand the importance of testing students at an application level, should teach students to apply theory to ensure safe and effective nursing care. Although standardized testing is a valuable tool in identifying knowledge gaps, remedial efforts should address alternative factors that contribute to poor testing outcomes. Culleiton12 concluded that remedial efforts should be based on students’ individual needs. Students possess not only content gaps, but also inadequate test-taking skills and testtaking anxiety. English and Gordon13 included visualization and guided imagery activities and test-taking strategy sessions to help 9 students successfully pass an exit examination. Stark et al14 also found that the ability to take multiple-choice tests and careful planning for the day of testing contributed to students’ success on nursing examinations. Evans and Harder15 recommended the use of simulation as an effective remedial strategy. It is important to design activities to enhance time management, promote test-taking skills, and correctly evaluate answer choice options. Faculty should also help students
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take the initiative to develop individualized study plans and access all available resources.2,4,8 By developing a remedial program that incorporates all of these factors, faculty empower students to take an active role in their learning. This student ‘‘buy-in’’ will increase student success on nursing examinations. The challenge for nurse educators today is to develop a sound multifaceted approach that promotes student success. The National League for Nursing has addressed this subject in a vision series document entitled, ‘‘The Fair Testing Imperative in Nursing Education.’’16 A major recommendation is for faculty to develop a policy that addresses multiple approaches to preparing students and assessing their learning and nursing competence. When RN programs address student weak areas and knowledge deficits in a proactive manner, students may be successful on standardized examinations such as program exit examinations and the NCLEX-RN. The purpose of this article was to describe how 1 baccalaureate nursing program created a proactive policy including a remediation plan to promote student success by addressing students’ strengths and areas for improvement supported by standardized testing.
Problem: The Initial Shock The initial shock occurred at a university-based traditional baccalaureate nursing program composed of a lower and upper division. The lower-division courses consist of prerequisites needed to enter the upper-division nursing curriculum. Clinical and nonclinical nursing courses make up the nursing program’s upper division. Similar to many nursing programs, standardized testing is used to promote student success. Students are required to pass the comprehensive exit examination as a requirement for program completion and graduation. Students are given 3 opportunities to pass the comprehensive exit examination. In fall 2008, this program experienced a decrease in comprehensive exit examination pass rates, culminating to a mere 56% (41 pass/73 students) following 3 attempts. Based on these data, faculty were unsure as to whether these students could be successful on the NLCEX-RN. Not willing to take that risk, faculty were charged with devising a comprehensive and multifaceted approach to address weak content areas, poor study habits, ineffective critical thinking, and poor test-taking skills, issues documented in the literature as being common challenges for nursing students.1,2 Administration charged faculty with the task of developing a plan that would correct these deficits so that students would be successful on the comprehensive exit examination and therefore the NCLEX-RN. To resolve this initial problem, faculty completed these charges without changes in faculty workload or additional financial compensation. As the policy evolved, faculty workload assignments included newly established courses created as a result of the Positive Progression policy. Faculty divided these 32 students who did not pass the exit examination into 4 groups of 8 students. Each group was assigned to 2 faculty members who taught medical-surgical nursing and 1 faculty member for each of the specialty areas including community health, mental health, maternal child, and pediatrics. In other words, there were 6 faculty assigned to every 8 students. Faculty met with students during scheduled discussion sessions. Each remediation session included a faculty-developed quiz of 10 questions. Faculty adminis286
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tered the quiz before every remediation session. Faculty openly reviewed and discussed the quizzes with the entire group. In addition to filling content and knowledge gaps, the open discussions improved critical thinking, clinical judgment, and test item analysis, 3 essential skills for nursing student success. Faculty also covered topics such as test-taking anxiety and effective study habits. With assistance, faculty required that students develop a formal and structured study plan. As a result of this aggressive intervention, 31 of these 32 students were able to pass the comprehensive exit examination and graduate from the program. The remaining student was unsuccessful because of unrelated issues. All 31 students passed the NCLEX-RN on their first attempt. The success of this reactive intervention led to the development and adoption of a proactive policy entitled, ‘‘Positive Progression,’’ which begins the on first semester of the nursing program.
Intervention: The Positive Progression Approach The Positive Progression approach was developed by faculty in response to an identified student need. The purpose of this approach is to promote student success in the 5 semesters of upper-division nursing courses in the undergraduate program. Because this is a multifaceted approach, each component (clinical nursing courses, remediation contract, 14-step Specialty Exit Exam Review, the critical-thinking and problemsolving courses, and the preparation for licensure course) comprising the approach is discussed.
Clinical Nursing Courses In the clinical nursing courses (a combination of clinical and theory hours), the faculty made a commitment to use the ‘‘lecture’’ teaching strategy minimally. Faculty post content information using lecture capture and PowerPoint slides on the learning management system. Students are expected to study this information prior to class. Class time is used to apply the knowledge through unfolding case studies, simulation, and other interactive teaching strategies. Students are also assigned case studies to complete outside class. The clinical experience mimics the theory content so that students are focusing on the same specific theory concept in clinical while performing safe patient-centered care. For example, if the concept of oxygenation was discussed in class, then the students’ focus in clinical is oxygenation in relation to the patient’s specific situation. This approach is supported by Benner and colleagues’17 work with the Carnegie Foundation that recommends ‘‘shifting from a sharp separation of clinical and classroom teaching to integration of classroom and clinical teaching.’’ Within each clinical course, a specialty exit examination is administered toward the end of the course and counts for 10% of the final grade. The exit examination posts a probability score as well as a conversion score. The conversion score (numerical score) is used as a component of the final course grade. In clinical nursing courses, the conversion score counts 10% of the final course grade, regardless of whether they score 900 or more. The examination vendor recommends a probability score of 850 (average probability) or 900 (excellent probability) as a benchmark for success.18 A 900 probability score was selected by the faculty as the benchmark for passing the specialty and comprehensive exit examinations. Nurse Educator
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Remediation Contract If a student scores less than 900 on the specialty or comprehensive exit examination, the student receives an incomplete in the enrolled course, and an individualized remediation plan is designed for the student. The remediation plan is a contract between the faculty and student. Table 1 addresses the components of the contract. Between semesters, students should complete the remediation plan and submit it 2 days prior to the start of the next semester. This allows faculty the opportunity to review the submitted remediation and determine if the student work is satisfactory or unsatisfactory. If the work is deemed satisfactory, the incomplete course grade is replaced with the original earned grade, and the student progresses to the next-semester courses; if unsatisfactory, the incomplete grade remains in place, and the student is required to take an independent study reflective of the theoretical information in which the student demonstrated deficits in knowledge. For example, if a student is unsuccessful with remediation in fundamentals, the student would be expected to take a fundamentals-independent study. If successful in the independent study, the incomplete grade is replaced with the original earned course grade, and the student progresses to the next-semester nursing courses. Fourteen-Step Exit Examination Review Students can practice the integration of knowledge by using a simple 14-step process (Table 2) created to assist student remediation based on specialty and comprehensive exit examination results. The 14 questions relevant to the care of persons with health problems prompt students to consider all aspects of the person as well as the health problem. These steps do not segregate health problems by clinical specialty such as obstetrics, pediatrics, or mental health but instead incorporate growth and development, culture, pharmacology, nutrition, pathophysiology, teaching, and usual treatments. Developed by a faculty member and based on years of experience working with students in a medical-surgical course, these questions facilitate a comprehensive approach to understanding care, and each of these components of caring for a person is reflected on the licensure examination and most standardized tests. Students should learn to synthesize their responses using their own words, not the words of textbooks. Responses to each question should be 1 to 2 sentences in length indicating that the student has analyzed the content from the references and synthesized the textbook response in the student’s own words. Students also benefit from referencing the sources of their responses to each question to
ensure that they are exploring multiple sources and reading more than only what is necessary to answer the question.
Courses Focusing on Problem Solving and Clinical Judgment Two approved critical-thinking courses were developed and included in the faculty workload. One elective course (1 credit hour) focusing on critical thinking and problem solving was placed in the first semester of upper-division nursing courses. This course provides opportunities for enhancement of problemsolving and decision-making skills. Students learn cognitive self-assessment and how to intervene with factors that may interfere with the problem-solving process. In addition, students learn to develop an individualized study plan, determine their unique style of learning, and manage test-taking anxiety, all skills that could be used throughout the entire nursing program. This course starts 3 weeks later than the other courses in the first semester (pathophysiology, informatics, professional concepts, and medication calculation) in an effort to build off of the content taught in the other courses, particularly pathophysiology. The second critical thinking course (2 credit hours), which focuses on gaining skills and knowledge in advanced problem solving and clinical judgment, is required for students if they are unsuccessful on their specialty examination. The course is not a ‘‘content’’ course, but rather a clinical reasoning course that uses more than a dozen active learning strategies to practice application and retention of theory content, a ‘‘leap’’ that is often difficult for students. Students in this course are encouraged to reflect on their recent clinical experiences, discuss case studies, complete Quality and Safety Education in Nursing critical-thinking activities, and practice role playing. If a student takes the first semester problem-solving elective, the student is not required to take the other clinical judgment course. Enrollment in the elective course remained high throughout each semester. Enrollment in the required critical-thinking/clinical judgment course decreased as more students took the elective course and performed successfully on their specialty examinations. Some students chose to take both courses, although not required. Required Preparation for Licensure Course This 1-hour synthesis course taught in the last semester of the senior year provides opportunities for students to assess individual knowledge acquisition and to implement strategies to ameliorate any knowledge deficiencies. During this course, students participate in face-to-face reviews of content by faculty and an online review course for the NCLEX-RN examination. In
Table 1. Components of the Faculty/Student Contract
& Review of performance on specialty exit examination administered in NUR ____ using the individualized scoring reports
& Identification of content strengths and weaknesses based on item descriptors for each examination & Discussion of 14 step review process & Discussion of mandatory assignment (review of all missed item descriptors on the specialty exit examination using the 14-step review process in typewritten form with references and the student’s individualized scoring report) and method of submission (in a pronged folder [no 3-ring binders will be accepted] with student’s name, course name, and course leader’s name on outside of folder) required to enter the next-semester courses (specify what courses that would be for the student) Copyright * 2008 by Leslie G. Cole and Marsha H. Adams of The University of Alabama Capstone College of Nursing. Reprinted with permission of Leslie G. Cole and Marsha H. Adams of The University of Alabama Capstone College of Nursing, July 2, 2014.
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Table 2. Fourteen-Step Specialty Exit Examination Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
What is the definition of this problem? Who usually has this problem? Male/female; adult/child; anyone What person usually has this problem? Adult/child/anyone What is the normal developmental stage (using Erikson’s Developmental Stages) of this person? Are there any cultural implications related to this problem? Describe the pathophysiology of the problem. Describe the usual medical and/or surgical treatment. What medications are typically used? Write 1 sentence about each medication. What potential complications may develop? What diagnostic tests should be monitored? List the normal and expected values. What nutritional considerations are appropriate for this person? What is the prognosis for a person with this problem? Describe the discharge teaching for a person with this problem. What modifiable risk behavior could this patient have engaged in to possibly decrease his/her risk for this condition?
Copyright * 2008 by Felicia Wood of The University of Alabama Capstone College of Nursing. Reprinted with permission of Felicia Wood of The University of Alabama Capstone College of Nursing, July 2, 2014.
this course, students take the comprehensive exit examination in which they are given 3 opportunities to achieve a 900 or higher probability score as discussed earlier. If the student is unsuccessful on the third attempt, the student is not eligible to graduate until successful completion of this requirement.
Pilot Findings To determine the effectiveness of the Positive Progression approach for increasing student success, a retrospective pilot study was conducted from a secondary examination data set to determine the effectiveness of this multifaceted intervention. Mean examination scores (specialty examinations, comprehensive exit examinations, and the NCLEX licensure examination) were examined for each graduating cohort from fall 2008 to spring 2013. Table 3 illustrates the average first-attempt pass rates (Q900) for this sample. The sample was made up of predominantly females (90%) and whites (92%); the mean age of the sample was 22 years. Each graduating class is made up of approximately 79 students. As shown in Table 3, preintervention (baseline) data are represented by the fall 2008 graduating class. Only 23% (16 students) in this cohort were successful (Q900) on their first attempt of the comprehensive exit examination. This
fall 2008 graduating class never achieved higher than a 52% class pass rate on any of the standardized examinations. Remarkably, this cohort achieved a 100% NCLEX first-attempt pass rate despite their low standardized testing performance throughout upper division. After faculty initiated the previously described intense remediation plan for this group of high-risk students, all 32 were able to pass the NCLEX on their first attempt. Because the Positive Progression approach did not become a formal policy until the spring 2009 semester, graduating cohorts from spring 2009 to fall 2010 were not able to receive the full benefit of the Positive Progression policy, beginning in their first semester of upper division. The spring 2011 graduating cohort was the first class to benefit fully from the Positive Progression approach and therefore the first cohort to take the critical-thinking and problem-solving course (n = 77). Benefitting from this intervention, 78% of the spring 2011 graduating cohort passed the comprehensive exit examination on their first attempt. This was a dramatic increase when compared with the fall 2008 comprehensive exit examination pass rate of only 23%. Graduating cohorts who experienced the Positive Progression approach beginning their first semester of upper
Table 3. Standardized Examination (First Attempt)/NCLEX (First Attempt) Percentage Pass Rates by Graduating Cohort a
Fall 2008 Spring 2009 Fall 2009 Spring 2010 Fall 2010 Spring 2011 Fall 2011 Spring 2012 Fall 2012 Spring 2013 a
Fundamentals
Adult Health
Mental Health
Maternal Child
Pediatrics
Community Health
Exit Exam
NCLEX
25 26 14 15 35 66 61 37 45 40
52 45 30 54 44 64 45 —b 44 64
21 39 26 52 56 68 56 54 51 52
49 55 73 88 60 85 71 83 73 84
47 36 61 72 53 75 65 62 62 92
47 35 54 67 55 75 —b 71 63 98
23 60 40 60 77 79 67 69 69 82
100 97.9 95.4 98.8 97.5 97.7 98.6 96.2 98.7 89.9
Preintervention (baseline) data. Data not available.
b
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division (from spring 2011 to spring 2013) had consistently higher overall pass rates on their specialty and comprehensive exit examinations when compared with the graduating cohorts (spring 2009 to fall 2010) who did not experience the Positive Progression approach until after at least 1 completed semester of upper division. Despite this, all graduating cohorts who experienced the Positive Progression approach at some point in upper division showed an overall increase in specialty and comprehensive exit examination pass rates. Preliminary data suggest that student specialty and comprehensive exit examination pass rates increased significantly when students entered a proactive, multifaceted progression approach to promote student success. The Positive Progression approach continues to enhance student success through this innovative and comprehensive method of active learning.
Discussion Based on pilot study results, it is evident that the Positive Progression approach is a successful method for promoting student success on standardized specialty examinations, as well as the comprehensive exit examinations, and can be easily replicated by nursing programs. The literature points out multiple factors that contribute to poor nursing student outcomes including test-taking anxiety, student inability to apply theory into clinical practice, content knowledge gaps, and poor clinical reasoning skills, study habits, and test-taking skills.1-4 In designing the Positive Progression approach, the faculty found all of these factors to be present, and any combination could occur among the nursing students. For example, some students demonstrated poor test-taking skills and anxiety when taking examinations, whereas others had clear knowledge deficits and an inability to apply content to clinical situations. The literature also stresses the importance of student selfassessment of content knowledge gaps, faculty assessment of content area gaps within the program, the need for individualized student action plans, and a proactive approach to student success rather than a reactive approach. The Positive Progression approach addresses all of these components. The combination of promoting clinical reasoning in newly developed criticalthinking/problem-solving courses and in the already established clinical nursing courses, designing individualized remediation plans specific for each student connecting test-item descriptors and the 14-step process, and finally participating in a preparation for licensure course, which provides intensive content reviews, are effective strategies for success.
Recommendations for the Future Designing and implementing this multifaceted approach was a challenging and time-consuming process. Other than logistical policy changes that occurred to conform to universitywide policies, the Positive Progression approach required many additional work hours. Faculty now have the added responsibility of meeting with students to develop individualized signed student contracts, grading the student remediation work, and updating student final course grades as the remediation work is deemed either satisfactory or unsatisfactory. Independent study courses have to be developed for students with unsatisfactory remediation work. Fortunately,
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since the implementation of this approach, fewer than 4 students have required an independent study. With any new initiative, one must weigh the pros and cons. Positive Progression is a college’s proactive, multifaceted, and innovative approach to student success, which fosters critical thinking, clinical judgment, student self-assessment, and individualized plans of action for student remediation. It is based on the existing evidence in the literature, and initial pilot data clearly support its success. Acknowledgment The authors thank Dr Felecia Wood for her design of the remediation tool described in this article.
References 1. Carr S. NCLEX-RN pass rate peril: one school’s journey through curriculum revision, standardized testing, and attitudinal change. Nurs Educ Pers. 2011;32(6):384-388. 2. Carrick J. Student achievement and NCLEX-RN success: problems that persist. Nurs Educ Pers. 2011;32(2):78-83. 3. Harding M. Efficacy of progression testing in predicting nursing student academic success. J Nurs Educ Prac. 2012;2(2):137-140. 4. Santo L, Frander E, Hawkins A. The use of standardized exit examinations in baccalaureate nursing education. Nurs Educ. 2013;38(2):81-84. 5. Heroff K. Guidelines for a progression and remediation policy using standardized tests to prepare associate degree nursing students or the NCLEX-RN at a rural community college. Nurs Educ. 2009;4:79-86. 6. Nibert A, Morrison S. HESI testing: a history of evidenced-based research. J Prof Nurs. 2013;29(2):S2-S4. 7. Mosser NR, Williams J, Wood C. Use of progression testing throughout nursing programs: How 2 colleges promote success on the NCLEX-RN. Annu Rev Nurs Educ. 2006;4:305-318. 8. Pennington TD, Spurlock D. A systematic review of the effectiveness of remediation interventions to improve NCLEX-RN pass rates. J Nurs Educ. 2010;49(9):485-492. 9. Morrison S, Free KW, Newman M. Do progression and remediation policies improve NCLEX-RN pass rates? Comput Inform Nurs. 2002;25(5):67S-69S. 10. Popil I. Promotion of critical thinking by using case studies as a teaching method. Nurs Educ Today. 2010;31:204-207. 11. Lasater K. Clinical judgment: the last frontier for evaluation. Nurs Educ Prac. 2011;11(20):86-92. 12. Culleiton AL. Remediation: a closer look in an educational context. Teach Learn Nurs. 2011;4:22-27. 13. English JB, Gordon DK. Successful student remediation following repeated failures on the HESI exam. Nurs Educ. 2004;29(6):266-268. 14. Starke MA, Feikema B, Wyngarden K. Empowering students for NCLEX success: Self-assessment and planning. Nurs Educ. 2002;27(3):103-105. 15. Evans C, Harder N. A formative approach to student remediation. Nurs Educ. 2013;38(4):147-151. 16. NLN vision series: The fair testing imperative in nursing education. National League for Nursing Web site. Published February 2012. Available at http://www.nln.org/aboutnln/livingdocuments/ pdf/nlnvision_4.pdf. Accessed July 23, 2012. 17. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Josey-Bass Publishing; 2010:83. 18. HESI Exit Exam. Elsevier HESI Exam Guide Web site. Published 2014. Available at http://www.hesi-exam.com/hesi-exit-exam/. Accessed July 3, 2014.
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Nurse Educator
A Multifaceted Progression Approach to Enhancing Student Success Leslie G. Cole, DNP, RN & Marsha H. Adams, PhD, RN, CNE, ANEF This article describes how a faculty rallied together and developed a positive progression approach to promote student success on standardized specialty and comprehensive examinations, which fosters critical thinking, clinical judgment, student self-assessment, and individualized plans of action. Specific strategies implemented are discussed. Aggregate student data related to course grades, specialty and comprehensive exit examination scores, and NCLEX pass rates support this innovative approach to student success. Keywords: exit examination; nursing students; progression testing; remediation; standardized testing; student success
A
s the nursing shortage continues to be a major healthcare concern, nursing programs are charged with the duty of increasing student retention and graduation rates and adequately preparing students for licensure. Licensure pass rates, a key benchmark for prelicensure nursing education programs, have been a popular topic in nursing education research. Nurse educators have repeatedly published literature to address low licensure pass rates.1-5 In an effort to prepare nursing students for NCLEX-RN, nursing programs have implemented total curriculum revision and the use of standardized testing and remediation programs.1 Nibert and Morrison,6 in a review of evidence-based research, suggested that the comprehensive exit examination (comprehensive standardized examination taken at the end of the nursing program prior to graduation) was ‘‘96.36% and 99.16%’’ accurate in predicting success on the licensure examination. Progression testing, the use of standardized testing in specific content areas, allows for measurement of content knowledge as students progress through nursing courses.4,6 Progression testing provides students an opportunity to experience testing that is similar to the NCLEX-RN.7 Standardized testing helps students identify areas of weakness, providing a helpful selfassessment of content and knowledge gaps.8 Santo et al4 stressed the importance of designing remedial programs based on students’ lack of knowledge in particular content areas. Nursing programs that use standardized testing as a tool to enhance student success should analyze testing reports to identify and strengthen weak areas in their nursing curriculum.
Author Affiliations: Assistant Professor (Dr Cole), Capstone College of Nursing, The University of Alabama, Tuscaloosa; Professor and Dean (Dr Adams), College of Nursing, The University of Alabama in Huntsville. The authors declare no conflicts of interest. Correspondence: Dr Cole, Box 870358, Tuscaloosa, AL 35487 ([email protected]). Accepted for publication: August 3, 2014 DOI: 10.1097/NNE.0000000000000084
Nurse Educator
After analyzing reports to determine weak content areas in their nursing program, faculty can determine if their current teaching strategies are effective in promoting knowledge retention.9 Because nursing is a practice profession that requires the application of theory in a clinical situation, nurse educators should use strategies that foster critical reasoning by engaging students in active learning processes.6 Active learning methods include case studies, discussion or debates, simulation, and role playing, among others.10 Students who appear to have knowledge gaps on nursing examinations may lack the ability to use their knowledge to practice safe and effective patient care. Because standardized and licensure examinations test the student’s ability to analyze knowledge and apply it to a patient situation, students who have poorly developed critical reasoning and clinical judgment skills will most likely perform poorly on these examinations. Lasater11 stated that thinking is not a linear process. Nurse educators, who understand the importance of testing students at an application level, should teach students to apply theory to ensure safe and effective nursing care. Although standardized testing is a valuable tool in identifying knowledge gaps, remedial efforts should address alternative factors that contribute to poor testing outcomes. Culleiton12 concluded that remedial efforts should be based on students’ individual needs. Students possess not only content gaps, but also inadequate test-taking skills and testtaking anxiety. English and Gordon13 included visualization and guided imagery activities and test-taking strategy sessions to help 9 students successfully pass an exit examination. Stark et al14 also found that the ability to take multiple-choice tests and careful planning for the day of testing contributed to students’ success on nursing examinations. Evans and Harder15 recommended the use of simulation as an effective remedial strategy. It is important to design activities to enhance time management, promote test-taking skills, and correctly evaluate answer choice options. Faculty should also help students
Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
285
take the initiative to develop individualized study plans and access all available resources.2,4,8 By developing a remedial program that incorporates all of these factors, faculty empower students to take an active role in their learning. This student ‘‘buy-in’’ will increase student success on nursing examinations. The challenge for nurse educators today is to develop a sound multifaceted approach that promotes student success. The National League for Nursing has addressed this subject in a vision series document entitled, ‘‘The Fair Testing Imperative in Nursing Education.’’16 A major recommendation is for faculty to develop a policy that addresses multiple approaches to preparing students and assessing their learning and nursing competence. When RN programs address student weak areas and knowledge deficits in a proactive manner, students may be successful on standardized examinations such as program exit examinations and the NCLEX-RN. The purpose of this article was to describe how 1 baccalaureate nursing program created a proactive policy including a remediation plan to promote student success by addressing students’ strengths and areas for improvement supported by standardized testing.
Problem: The Initial Shock The initial shock occurred at a university-based traditional baccalaureate nursing program composed of a lower and upper division. The lower-division courses consist of prerequisites needed to enter the upper-division nursing curriculum. Clinical and nonclinical nursing courses make up the nursing program’s upper division. Similar to many nursing programs, standardized testing is used to promote student success. Students are required to pass the comprehensive exit examination as a requirement for program completion and graduation. Students are given 3 opportunities to pass the comprehensive exit examination. In fall 2008, this program experienced a decrease in comprehensive exit examination pass rates, culminating to a mere 56% (41 pass/73 students) following 3 attempts. Based on these data, faculty were unsure as to whether these students could be successful on the NLCEX-RN. Not willing to take that risk, faculty were charged with devising a comprehensive and multifaceted approach to address weak content areas, poor study habits, ineffective critical thinking, and poor test-taking skills, issues documented in the literature as being common challenges for nursing students.1,2 Administration charged faculty with the task of developing a plan that would correct these deficits so that students would be successful on the comprehensive exit examination and therefore the NCLEX-RN. To resolve this initial problem, faculty completed these charges without changes in faculty workload or additional financial compensation. As the policy evolved, faculty workload assignments included newly established courses created as a result of the Positive Progression policy. Faculty divided these 32 students who did not pass the exit examination into 4 groups of 8 students. Each group was assigned to 2 faculty members who taught medical-surgical nursing and 1 faculty member for each of the specialty areas including community health, mental health, maternal child, and pediatrics. In other words, there were 6 faculty assigned to every 8 students. Faculty met with students during scheduled discussion sessions. Each remediation session included a faculty-developed quiz of 10 questions. Faculty adminis286
Volume 39 & Number 6 & November/December 2014
tered the quiz before every remediation session. Faculty openly reviewed and discussed the quizzes with the entire group. In addition to filling content and knowledge gaps, the open discussions improved critical thinking, clinical judgment, and test item analysis, 3 essential skills for nursing student success. Faculty also covered topics such as test-taking anxiety and effective study habits. With assistance, faculty required that students develop a formal and structured study plan. As a result of this aggressive intervention, 31 of these 32 students were able to pass the comprehensive exit examination and graduate from the program. The remaining student was unsuccessful because of unrelated issues. All 31 students passed the NCLEX-RN on their first attempt. The success of this reactive intervention led to the development and adoption of a proactive policy entitled, ‘‘Positive Progression,’’ which begins the on first semester of the nursing program.
Intervention: The Positive Progression Approach The Positive Progression approach was developed by faculty in response to an identified student need. The purpose of this approach is to promote student success in the 5 semesters of upper-division nursing courses in the undergraduate program. Because this is a multifaceted approach, each component (clinical nursing courses, remediation contract, 14-step Specialty Exit Exam Review, the critical-thinking and problemsolving courses, and the preparation for licensure course) comprising the approach is discussed.
Clinical Nursing Courses In the clinical nursing courses (a combination of clinical and theory hours), the faculty made a commitment to use the ‘‘lecture’’ teaching strategy minimally. Faculty post content information using lecture capture and PowerPoint slides on the learning management system. Students are expected to study this information prior to class. Class time is used to apply the knowledge through unfolding case studies, simulation, and other interactive teaching strategies. Students are also assigned case studies to complete outside class. The clinical experience mimics the theory content so that students are focusing on the same specific theory concept in clinical while performing safe patient-centered care. For example, if the concept of oxygenation was discussed in class, then the students’ focus in clinical is oxygenation in relation to the patient’s specific situation. This approach is supported by Benner and colleagues’17 work with the Carnegie Foundation that recommends ‘‘shifting from a sharp separation of clinical and classroom teaching to integration of classroom and clinical teaching.’’ Within each clinical course, a specialty exit examination is administered toward the end of the course and counts for 10% of the final grade. The exit examination posts a probability score as well as a conversion score. The conversion score (numerical score) is used as a component of the final course grade. In clinical nursing courses, the conversion score counts 10% of the final course grade, regardless of whether they score 900 or more. The examination vendor recommends a probability score of 850 (average probability) or 900 (excellent probability) as a benchmark for success.18 A 900 probability score was selected by the faculty as the benchmark for passing the specialty and comprehensive exit examinations. Nurse Educator
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Remediation Contract If a student scores less than 900 on the specialty or comprehensive exit examination, the student receives an incomplete in the enrolled course, and an individualized remediation plan is designed for the student. The remediation plan is a contract between the faculty and student. Table 1 addresses the components of the contract. Between semesters, students should complete the remediation plan and submit it 2 days prior to the start of the next semester. This allows faculty the opportunity to review the submitted remediation and determine if the student work is satisfactory or unsatisfactory. If the work is deemed satisfactory, the incomplete course grade is replaced with the original earned grade, and the student progresses to the next-semester courses; if unsatisfactory, the incomplete grade remains in place, and the student is required to take an independent study reflective of the theoretical information in which the student demonstrated deficits in knowledge. For example, if a student is unsuccessful with remediation in fundamentals, the student would be expected to take a fundamentals-independent study. If successful in the independent study, the incomplete grade is replaced with the original earned course grade, and the student progresses to the next-semester nursing courses. Fourteen-Step Exit Examination Review Students can practice the integration of knowledge by using a simple 14-step process (Table 2) created to assist student remediation based on specialty and comprehensive exit examination results. The 14 questions relevant to the care of persons with health problems prompt students to consider all aspects of the person as well as the health problem. These steps do not segregate health problems by clinical specialty such as obstetrics, pediatrics, or mental health but instead incorporate growth and development, culture, pharmacology, nutrition, pathophysiology, teaching, and usual treatments. Developed by a faculty member and based on years of experience working with students in a medical-surgical course, these questions facilitate a comprehensive approach to understanding care, and each of these components of caring for a person is reflected on the licensure examination and most standardized tests. Students should learn to synthesize their responses using their own words, not the words of textbooks. Responses to each question should be 1 to 2 sentences in length indicating that the student has analyzed the content from the references and synthesized the textbook response in the student’s own words. Students also benefit from referencing the sources of their responses to each question to
ensure that they are exploring multiple sources and reading more than only what is necessary to answer the question.
Courses Focusing on Problem Solving and Clinical Judgment Two approved critical-thinking courses were developed and included in the faculty workload. One elective course (1 credit hour) focusing on critical thinking and problem solving was placed in the first semester of upper-division nursing courses. This course provides opportunities for enhancement of problemsolving and decision-making skills. Students learn cognitive self-assessment and how to intervene with factors that may interfere with the problem-solving process. In addition, students learn to develop an individualized study plan, determine their unique style of learning, and manage test-taking anxiety, all skills that could be used throughout the entire nursing program. This course starts 3 weeks later than the other courses in the first semester (pathophysiology, informatics, professional concepts, and medication calculation) in an effort to build off of the content taught in the other courses, particularly pathophysiology. The second critical thinking course (2 credit hours), which focuses on gaining skills and knowledge in advanced problem solving and clinical judgment, is required for students if they are unsuccessful on their specialty examination. The course is not a ‘‘content’’ course, but rather a clinical reasoning course that uses more than a dozen active learning strategies to practice application and retention of theory content, a ‘‘leap’’ that is often difficult for students. Students in this course are encouraged to reflect on their recent clinical experiences, discuss case studies, complete Quality and Safety Education in Nursing critical-thinking activities, and practice role playing. If a student takes the first semester problem-solving elective, the student is not required to take the other clinical judgment course. Enrollment in the elective course remained high throughout each semester. Enrollment in the required critical-thinking/clinical judgment course decreased as more students took the elective course and performed successfully on their specialty examinations. Some students chose to take both courses, although not required. Required Preparation for Licensure Course This 1-hour synthesis course taught in the last semester of the senior year provides opportunities for students to assess individual knowledge acquisition and to implement strategies to ameliorate any knowledge deficiencies. During this course, students participate in face-to-face reviews of content by faculty and an online review course for the NCLEX-RN examination. In
Table 1. Components of the Faculty/Student Contract
& Review of performance on specialty exit examination administered in NUR ____ using the individualized scoring reports
& Identification of content strengths and weaknesses based on item descriptors for each examination & Discussion of 14 step review process & Discussion of mandatory assignment (review of all missed item descriptors on the specialty exit examination using the 14-step review process in typewritten form with references and the student’s individualized scoring report) and method of submission (in a pronged folder [no 3-ring binders will be accepted] with student’s name, course name, and course leader’s name on outside of folder) required to enter the next-semester courses (specify what courses that would be for the student) Copyright * 2008 by Leslie G. Cole and Marsha H. Adams of The University of Alabama Capstone College of Nursing. Reprinted with permission of Leslie G. Cole and Marsha H. Adams of The University of Alabama Capstone College of Nursing, July 2, 2014.
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Table 2. Fourteen-Step Specialty Exit Examination Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
What is the definition of this problem? Who usually has this problem? Male/female; adult/child; anyone What person usually has this problem? Adult/child/anyone What is the normal developmental stage (using Erikson’s Developmental Stages) of this person? Are there any cultural implications related to this problem? Describe the pathophysiology of the problem. Describe the usual medical and/or surgical treatment. What medications are typically used? Write 1 sentence about each medication. What potential complications may develop? What diagnostic tests should be monitored? List the normal and expected values. What nutritional considerations are appropriate for this person? What is the prognosis for a person with this problem? Describe the discharge teaching for a person with this problem. What modifiable risk behavior could this patient have engaged in to possibly decrease his/her risk for this condition?
Copyright * 2008 by Felicia Wood of The University of Alabama Capstone College of Nursing. Reprinted with permission of Felicia Wood of The University of Alabama Capstone College of Nursing, July 2, 2014.
this course, students take the comprehensive exit examination in which they are given 3 opportunities to achieve a 900 or higher probability score as discussed earlier. If the student is unsuccessful on the third attempt, the student is not eligible to graduate until successful completion of this requirement.
Pilot Findings To determine the effectiveness of the Positive Progression approach for increasing student success, a retrospective pilot study was conducted from a secondary examination data set to determine the effectiveness of this multifaceted intervention. Mean examination scores (specialty examinations, comprehensive exit examinations, and the NCLEX licensure examination) were examined for each graduating cohort from fall 2008 to spring 2013. Table 3 illustrates the average first-attempt pass rates (Q900) for this sample. The sample was made up of predominantly females (90%) and whites (92%); the mean age of the sample was 22 years. Each graduating class is made up of approximately 79 students. As shown in Table 3, preintervention (baseline) data are represented by the fall 2008 graduating class. Only 23% (16 students) in this cohort were successful (Q900) on their first attempt of the comprehensive exit examination. This
fall 2008 graduating class never achieved higher than a 52% class pass rate on any of the standardized examinations. Remarkably, this cohort achieved a 100% NCLEX first-attempt pass rate despite their low standardized testing performance throughout upper division. After faculty initiated the previously described intense remediation plan for this group of high-risk students, all 32 were able to pass the NCLEX on their first attempt. Because the Positive Progression approach did not become a formal policy until the spring 2009 semester, graduating cohorts from spring 2009 to fall 2010 were not able to receive the full benefit of the Positive Progression policy, beginning in their first semester of upper division. The spring 2011 graduating cohort was the first class to benefit fully from the Positive Progression approach and therefore the first cohort to take the critical-thinking and problem-solving course (n = 77). Benefitting from this intervention, 78% of the spring 2011 graduating cohort passed the comprehensive exit examination on their first attempt. This was a dramatic increase when compared with the fall 2008 comprehensive exit examination pass rate of only 23%. Graduating cohorts who experienced the Positive Progression approach beginning their first semester of upper
Table 3. Standardized Examination (First Attempt)/NCLEX (First Attempt) Percentage Pass Rates by Graduating Cohort a
Fall 2008 Spring 2009 Fall 2009 Spring 2010 Fall 2010 Spring 2011 Fall 2011 Spring 2012 Fall 2012 Spring 2013 a
Fundamentals
Adult Health
Mental Health
Maternal Child
Pediatrics
Community Health
Exit Exam
NCLEX
25 26 14 15 35 66 61 37 45 40
52 45 30 54 44 64 45 —b 44 64
21 39 26 52 56 68 56 54 51 52
49 55 73 88 60 85 71 83 73 84
47 36 61 72 53 75 65 62 62 92
47 35 54 67 55 75 —b 71 63 98
23 60 40 60 77 79 67 69 69 82
100 97.9 95.4 98.8 97.5 97.7 98.6 96.2 98.7 89.9
Preintervention (baseline) data. Data not available.
b
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division (from spring 2011 to spring 2013) had consistently higher overall pass rates on their specialty and comprehensive exit examinations when compared with the graduating cohorts (spring 2009 to fall 2010) who did not experience the Positive Progression approach until after at least 1 completed semester of upper division. Despite this, all graduating cohorts who experienced the Positive Progression approach at some point in upper division showed an overall increase in specialty and comprehensive exit examination pass rates. Preliminary data suggest that student specialty and comprehensive exit examination pass rates increased significantly when students entered a proactive, multifaceted progression approach to promote student success. The Positive Progression approach continues to enhance student success through this innovative and comprehensive method of active learning.
Discussion Based on pilot study results, it is evident that the Positive Progression approach is a successful method for promoting student success on standardized specialty examinations, as well as the comprehensive exit examinations, and can be easily replicated by nursing programs. The literature points out multiple factors that contribute to poor nursing student outcomes including test-taking anxiety, student inability to apply theory into clinical practice, content knowledge gaps, and poor clinical reasoning skills, study habits, and test-taking skills.1-4 In designing the Positive Progression approach, the faculty found all of these factors to be present, and any combination could occur among the nursing students. For example, some students demonstrated poor test-taking skills and anxiety when taking examinations, whereas others had clear knowledge deficits and an inability to apply content to clinical situations. The literature also stresses the importance of student selfassessment of content knowledge gaps, faculty assessment of content area gaps within the program, the need for individualized student action plans, and a proactive approach to student success rather than a reactive approach. The Positive Progression approach addresses all of these components. The combination of promoting clinical reasoning in newly developed criticalthinking/problem-solving courses and in the already established clinical nursing courses, designing individualized remediation plans specific for each student connecting test-item descriptors and the 14-step process, and finally participating in a preparation for licensure course, which provides intensive content reviews, are effective strategies for success.
Recommendations for the Future Designing and implementing this multifaceted approach was a challenging and time-consuming process. Other than logistical policy changes that occurred to conform to universitywide policies, the Positive Progression approach required many additional work hours. Faculty now have the added responsibility of meeting with students to develop individualized signed student contracts, grading the student remediation work, and updating student final course grades as the remediation work is deemed either satisfactory or unsatisfactory. Independent study courses have to be developed for students with unsatisfactory remediation work. Fortunately,
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since the implementation of this approach, fewer than 4 students have required an independent study. With any new initiative, one must weigh the pros and cons. Positive Progression is a college’s proactive, multifaceted, and innovative approach to student success, which fosters critical thinking, clinical judgment, student self-assessment, and individualized plans of action for student remediation. It is based on the existing evidence in the literature, and initial pilot data clearly support its success. Acknowledgment The authors thank Dr Felecia Wood for her design of the remediation tool described in this article.
References 1. Carr S. NCLEX-RN pass rate peril: one school’s journey through curriculum revision, standardized testing, and attitudinal change. Nurs Educ Pers. 2011;32(6):384-388. 2. Carrick J. Student achievement and NCLEX-RN success: problems that persist. Nurs Educ Pers. 2011;32(2):78-83. 3. Harding M. Efficacy of progression testing in predicting nursing student academic success. J Nurs Educ Prac. 2012;2(2):137-140. 4. Santo L, Frander E, Hawkins A. The use of standardized exit examinations in baccalaureate nursing education. Nurs Educ. 2013;38(2):81-84. 5. Heroff K. Guidelines for a progression and remediation policy using standardized tests to prepare associate degree nursing students or the NCLEX-RN at a rural community college. Nurs Educ. 2009;4:79-86. 6. Nibert A, Morrison S. HESI testing: a history of evidenced-based research. J Prof Nurs. 2013;29(2):S2-S4. 7. Mosser NR, Williams J, Wood C. Use of progression testing throughout nursing programs: How 2 colleges promote success on the NCLEX-RN. Annu Rev Nurs Educ. 2006;4:305-318. 8. Pennington TD, Spurlock D. A systematic review of the effectiveness of remediation interventions to improve NCLEX-RN pass rates. J Nurs Educ. 2010;49(9):485-492. 9. Morrison S, Free KW, Newman M. Do progression and remediation policies improve NCLEX-RN pass rates? Comput Inform Nurs. 2002;25(5):67S-69S. 10. Popil I. Promotion of critical thinking by using case studies as a teaching method. Nurs Educ Today. 2010;31:204-207. 11. Lasater K. Clinical judgment: the last frontier for evaluation. Nurs Educ Prac. 2011;11(20):86-92. 12. Culleiton AL. Remediation: a closer look in an educational context. Teach Learn Nurs. 2011;4:22-27. 13. English JB, Gordon DK. Successful student remediation following repeated failures on the HESI exam. Nurs Educ. 2004;29(6):266-268. 14. Starke MA, Feikema B, Wyngarden K. Empowering students for NCLEX success: Self-assessment and planning. Nurs Educ. 2002;27(3):103-105. 15. Evans C, Harder N. A formative approach to student remediation. Nurs Educ. 2013;38(4):147-151. 16. NLN vision series: The fair testing imperative in nursing education. National League for Nursing Web site. Published February 2012. Available at http://www.nln.org/aboutnln/livingdocuments/ pdf/nlnvision_4.pdf. Accessed July 23, 2012. 17. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Josey-Bass Publishing; 2010:83. 18. HESI Exit Exam. Elsevier HESI Exam Guide Web site. Published 2014. Available at http://www.hesi-exam.com/hesi-exit-exam/. Accessed July 3, 2014.
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