Improving NCLEX-RN first-time pass rates with a balanced curriculum.
AbstractThe comprehensive changes made to the school of nursing's curriculum have allowed the educators and students to experience several positive outcomes. This article describes the challenges faced by the school of nursing in the past four years and the collaborative practices that the faculty and students have engaged in that have culminated in an improved NCLEX-RN first-time pass rate.
KEY WORDS
NCLEX-RN Pass Rates--Balanced Curriculum--Remediation--Nursing Education
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Mississippi is participating in a pilot project to implement recommendations set forth in the 2011 Institute of Medicine (IOM) report for the adoption of a competency-based nursing education model with a seamless academic transition from community college to university. The overall goal is to improve nursing education while increasing the number of baccalaureate-prepared nurses to 80 percent and doubling the number of doctorally prepared nurses by 2020. The Education Redesign Committee of the Mississippi Council of Deans and Directors of Schools of Nursing invited all nursing programs, from all levels, to unite and thoroughly examine program curricula to strengthen and improve educational outcomes.
This school of nursing (SON) is part of a midsized university located in the Mississippi delta. Each academic year, the baccalaureate program admits approximately 35 students with an average age of 27. Most of the students are women; 25 percent are African American and 74 percent are Caucasian. The program entails 15 separate specialty courses that span the course of 2.5 years. The program came under scrutiny by the Mississippi Institutions of Higher Learning (IHL) and the president of the university after the NCLEX-RN[R] pass rate fell to 72 percent in 2007 (McCrory, 2011). The poor NCLEX performance challenged faculty to systematically review all aspects of the nursing program and identify strengths and weaknesses as recommended by Pennington and Spurlock (2010). The SON has implemented the best practices to improve NCLEX-RN exam results that Carrick (2011) identified in the areas of academic policy, assessment of learning outcomes, curriculum and teaching approaches, and remediation and student support.
ACADEMIC POLICY
A review of academic standards for admission led to the determination that entrance requirements would need to be more stringent. Prospective students were graded using a formula that included a preadmission Health Education Systems (HESI[R]) score with a cutoff rate of 80 percent, an American College Testing (ACT) score with a minimum of 21, and a competitive cumulative grade point average (GPA). An analysis of all components of preadmission HESI scores revealed that low anatomy and physiology scores were correlated with low pathophysiology grades in the first semester. It has been shown that pathophysiology grades and ACT English subscores are highly predictive of student success in BSN programs (Landry, Davis, Alameida, Prive, & Renwanz-Boyle, 2010).
Faculty adopted a progression policy that would require students to meet higher expectations. A midcurricular HESI exam was implemented for the purpose of evaluating students' strengths and weaknesses prior to the capstone course; a cutoff score of 900 was implemented (Nibert, Young, & Britt, 2003). After the exam, students meet with their advisers to develop a plan of action. The minimum passing score for each course was increased from 74 percent to 76 percent.
ASSESSMENT OF LEARNING OUTCOMES
Several predictors of first-time NCLEX-RN success have been identified in the literature, including nursing program GPA (Alameida et al., 2011) and academic performance in psychiatric/mental health, pharmacology, and fundamentals (Landry et al., 2010). The chair of academic programs (COAP) identified a need to evaluate all nursing courses for rigor and substantiality. Besides aligning content and evaluation tools with the NCLEX-RN test blueprint, courses were examined using the revised Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008; Forbes & Hickey, 2009). A hard copy of each course analysis was submitted to the COAP to identify gaps in the continuity of concepts.
The capstone course, Nursing Synthesis, had been reconstructed in 2007 from a two-credit, self-study course to a three-credit course that required weekly class attendance. This is a preparatory course that reviews specific content areas that directly or indirectly reflect NCLEX-RN subject matter (e.g., pharmacology, professionalism, medical-surgical nursing, maternal-child, management of client care, and delegation principles). Students are required to take three standardized exit exams that account for 95 percent of the course grade and a self-study remediation plan based on exit exam scores. Students who do not obtain the minimum score of 900 are assigned an "in progress grade" and have one additional year to meet the course outcomes. Students who fell short of the 900 score demonstrated other results consistent with the literature (Frith, Sewell, & Clark, 2005), for example, low GPA and many "Cs." The standardized exams provide a detailed, quantitative analysis of student strengths/weaknesses that has been helpful in preparing an individualized, comprehensive plan for success.
In 2010, it was determined that students were experiencing problems understanding the integrated concepts of pathopharmacology. The decision was made to split this course into two separate courses: pathophysiology and pharmacology. Poor student performance on dosage calculation tests and substandard writing skills revealed that it was necessary to provide structured learning experiences that would help students improve in these areas. Thus, the Fundamentals instructor began to include an interactive dosage calculation seminar in the first week of class to teach and review fundamental calculation skills. Knowledge was then applied to scenarios using simulation medications and syringes. The testing policy was revised to include two dosage calculation questions in all undergraduate courses across the curriculum.
With dismay, it was found that the majority of students continued to experience difficulty in writing papers, with poor understanding of APA format. An assignment that promoted high quality writing skills was added to most courses. One course, Health Policy and Ethical Decision-Making, has been instrumental in improving writing skills with the requirement that students write and present a substantial scholarly paper using APA format.
All courses at the undergraduate level are hybrid courses that utilize an online component within Blackboard. Prior to 2008, instructors used their own designs and built their own courses without outside scrutiny. The decision was made to homogenize courses by standardizing the online component, to be consistent in formatting and allow for peer evaluation. Courses are now saved as "master copies" that can be accessed later.
Consistent with the goal of including technological innovation within the program of study, the school purchased Nursing School Tracking System (NSST) from TyphonGroup Healthcare Solutions. Information from this system allows faculty to follow each student throughout the program and to track whether the student is succeeding in clinical experiences. An additional benefit is an electronic portfolio option that allows students to showcase selected work representing an array of artifacts. Other technologies that promote student engagement include clicker technology and Blackboard Collaborate, which enables interactive instruction in an online environment.
In 2009, the school of nursing incorporated low-fidelity and high-fidelity simulations into the curriculum. Numerous benefits have been reported with the use of simulation, including uncompromised patient safety, improved cognitive and psychomotor skills, greater use of reflection on practice, and enhanced confidence and self-efficacy (DeBourgh & Prion, 2011; Shepherd, 2010). Studies purport that high-fidelity simulation bridges theory and practice and encourages student-centered learning (Elfrink, Kirkpatrick, Nininger, & Schubert, 2010)
The simulation director adopted the Jeffries Nursing Education Simulation Framework, which has been shown to be effective for developing scenarios that incorporate best teaching practices (Jeffries, 2007). Simulation designs are well thought out and include specific objectives, awareness of the problem-solving process, student support, and debriefing and reflection. Scenarios are peer reviewed to ensure accuracy and simulations are piloted prior to implementation. Debriefing and reflection are used to integrate the concepts presented in the simulation (Swanson et al., 2011).
Faculty identified a weakness in test-taking skills and study tactics that had an impact on NCLEX scores (Bonus, Taft, & Wendler, 2007). The decision was made to purchase another standardized testing program (ATI) (Davenport, 2007), which offers several learning activities and an extensive bank of test items. Each specialty course at the SON utilizes the program as self-study modules or as a standardized testing measure. An NCLEX-RN review course is offered to nursing students at the end of the nursing program. Students report that the course helps them consolidate information and improves their self-confidence.
Faculty development needs have been determined collaboratively. A faculty survey showed a need for support in several areas, including test writing, simulation instruction, teaching critical thinking, online instruction, scholarly writing, and working toward nurse educator certification.
REMEDIATION AND STUDENT SUPPORT
Today, all students in the SON are closely monitored for progression in each course, and counseling and remediation are provided for low performance on examinations. A full-time, licensed counselor is on site to work with students at risk for failure. Services are extensive and include psychological counseling, test-taking strategies, and time-management techniques. These confidential services are used extensively throughout the semester, especially toward the year end, when final exams are pending.
In 2010, an enhancement interventionist was hired to further assist students with personal areas of difficulty. This specialist provides a myriad of services, including personal tutoring and organizing classes that address identified common learning needs. The interventionist has been instrumental in improving student outcomes on both standardized exams and teacher-made tests.
Other support services provided by the SON include a weeklong Boot Camp immediately prior to the first semester in the program. The Boot Camp was designed to prepare newcomers for the rigors of the nursing program. It includes topics such as anatomy and physiology review, study techniques, and dosage calculation, as well as general content. Students are encouraged to mentor and tutor one another and identify stress reduction techniques.
THE OUTCOMES OF CURRICULAR CHANGES
Similar to the findings by March and Ambrose (2010), the changes described in this article have led to improved first-write pass rates on the NCLEX-RN licensure examination. A pass rate of 96.4 was reported for 2011. The faculty is proud of these results and continues to adjust course content while identifying best teaching-learning practices to improve student outcomes.
doi: 10.5480/11-591.1
REFERENCES
Alameida, M., Prive, A., Davis, H, Landry, L., Renwanz-Boyle, A., & Dunham, M. (2011). Predicting NCLEX-RN success in a diverse student population, journal of Nursing Education, 50(5), 261-267. doi:10.3928/01484834-20110228-01
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from www.aacn.nche.edu/ education-resources/BaccEssentials08.pdf
Bonus, S., Taft, L., & Wendler, C. (2007). Strategies to promote success on the NCLEX-RN: An evidence-based approach using the ACE Star Model of Knowledge Transformation. Nursing Education Perspectives, 28(2), 82-87. doi:10.1043/1536-5026(2007)028[0082:STPSOT]2.0.CO;2
Carrick, J. A. (2011). Student achievement and NCLEX-RN success: Problems that persist. Nursing Education Perspectives, 32(2), 78-83. doi:10.5480/1536-502632.2.78
Davenport, N. C. (2007). A comprehensive approach to NCLEX-RN success. Nursing Education Perspectives, 28(1), 30-33. doi:10.1043/1536-5026(2007)028[0030:ACA TNS]2.0.CO;2
DeBourgh, G. A., & Prion, S. K. (2011). Using simulation to teach prelicensure nursing students to minimize patient risk and harm. Clinical Simulation in Nursing, 7, e47-e56. doi:10.1016/j.ecns.2009.12.009
Elfrink, V., Kirkpatrick, B., Nininger, J., & Schubert. (2010). Using learning outcomes to inform teaching practices in human patient simulation. Nursing Education Perspectives, 31(2), 97-100. doi:10.1043/1536-5026-31.2.97
Forbes, M., & Hickey, M. (2009). Curriculum reform in baccalaureate nursing education: Review of the literature. International journal of Nursing Education Scholarship, 6(10), 1-16.
Frith, K., Sewell, J., & Clark, D. (2005). Best practices in NCLEX-RN readiness preparation for baccalaureate student success. CIN: Computers, Informatics, Nursing, 23(6), 46S-52S.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Jeffries, P. R. (Ed.). (2007). Simulation in nursing education: Prom conceptualization to evaluation. New York, NY: National League for Nursing.
Landry, L., Davis, H., Alameida, M., Prive, A., & Renwanz-Boyle, A. (2010). Predictors of NCLEX-RN success across 3 prelicensure program types. Nurse Educator, 33(6), 259-263. doi:10.1097/NNE.0b013e3181f7f1c9
March, K. S., & Ambrose, J. M. (2010). Rx for NCLEX-RN success: Reflections on development of an effective preparation process for senior baccalaureate students. Nursing Education Perspectives, 31(4), 230-232. doi:10.1043/1536-502631.4.230
McCrory, J. (2011, May 19). Annual report for Mississippi nursing degree programs: Nursing education in Mississippi. Retrieved from www.ihl.state.ms.us/nursing/
Nibert, A., Young, A., & Britt, R. (2003). The HESI exit exam progression benchmark and remediation guide. CIN: Computers, Informatics, Nursing, 28(3), 141-145.
Pennington, T., & Spurlock, D. (2010). A systematic review of the effectiveness of remediation interventions to improve NCLEX-RN pass rates, journal of Nursing Education, 49(9), 485-492. doi:10.3928/01484834-20100630-05
Shepherd, S. K. (2010). Investigating the use of simulation as a teaching strategy. Nursing Standard, 24(35), 42-48.
Swanson, E. A., Nicholson, A. G., Boese, T. A., Cram, E., Stineman, A. M., & Tew, K. (2011). Comparison of selected teaching strategies incorporating simulation and student outcomes. Clinical Simulation in Nursing, 7(3), e81-e90. doi:10.1016/j.ecns.2009.12.011
Donna L. Koestler, EdD, MSN, RN, is a nursing instructor at Robert E. Smith School of Nursing in Cleveland, Mississippi. For more information, contact her at [email protected].
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| Title Annotation: | Innovation Center |
|---|---|
| Author: | Koestler, Donna L. |
| Publication: | Nursing Education Perspectives |
| Article Type: | Report |
| Date: | Jan 1, 2015 |
| Words: | 2197 |
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