The Nurse Reinvestment Act of 2002 has the potential to educate the thousands of new nurses who are needed to reverse workforce shortages. However, nursing faculties and administrators face an important concern: Where will nursing programs find eligible applicants? One plausible solution, which is not a new concept, is the recruitment of culturally-diverse groups into nursing.1-4 Efforts to increase diversity within nursing began in the late 1970s, but met with limited success. Minority nurses comprised 12% of the total RN population in 2000, compared to 7% in 1980.1 However, diversity within nursing remains inconsistent with the general population. While the minority population in the nursing profession was 12% in 2000, it was 30% in the general U.S. population that same year.5
Earlier studies identified common barriers to the recruitment, admission, and retention of minority groups within colleges and universities. Findings indicated that a lack of academic preparedness in the sciences and English, poor career preparation offered by high school counselors, financial constraints, and a lack of adequate scholarships negatively affected this group's ability to succeed in college.1,3,6,7 Based on a review of the literature, Enders8 concluded that ethnic minorities and foreign-born graduates experienced more difficulty in completing the nursing curriculum, and that those who did complete the curriculum were at greater risk of failing the licensure examination than students of the majority culture. Additionally, minorities entering nursing schools reported feelings of social isolation, alienation, and racism, including a pattern of institutional racism espoused by some universities.1,3,6,7
To combat rising attrition rates among culturally diverse students and reverse the trend of declining NCLEX pass rates, nursing faculties have structured formal and informal support programs intended to bolster academic skills, address nursing knowledge deficits, and facilitate social support systems within the collegiate environment.6,9-16 Many of these remediation programs have been implemented in the final semester of the nursing program, and they have focused on student weaknesses in specific NCLEX content categories.
While evidence exists indicating that remediation positively affects NCLEX success in students with known academic deficits, few authors have described specific benchmarks that identify students who are at risk of NCLEX failure and in need of remediation. A new and growing trend among nursing faculties is to set benchmarks that contain progression-to-graduation requirements based on student performance on standardized nursing exams that allow for comparison with national norms. These policies are designed to identify students who are in need of remediation prior to graduation and NCLEX candidacy so that remediation can be initiated and NCLEX failure averted.
Comprehensive exams, including Williams and Wilkins' Computer-Assisted Preparation for the NCLEX-RN, Mosby's AssessTest, National League for Nursing (NLN) Achievement Tests, NLN Comprehensive Achievement Test, and NLN Diagnostic Readiness Test, have all demonstrated the ability to predict NCLEX success with varying degrees of accuracy.17-24 Carpenter and Bailey25 reviewed 67 studies published between 1976 and 1998 that focused on predictors of licensure success. Their findings indicated that: (1) all types of nursing programs leading to RN licensure shared similar predictors of NCLEX success; (2) academic ability and high school rank positively correlated with NCLEX success; and (3) nursing theory course scores and National League for Nursing (NLN) Achievement Test scores appeared to be the best predictors of success. The researchers concluded that consistently stable or reliable predictors of NCLEX success were not clearly identifiable and that the search for accurate predictors required more study. Several of the NCLEX simulation exams described by these authors are published in a paper-and-pencil format only, which causes a delay in the scoring and potentially hinders the usefulness of these exams as a guide for remediation. Therefore, nursing faculties have increasingly selected computerized NCLEX simulation exams, not only because they can provide instant scoring data, but also because they can simulate the Computerized Adaptive Testing (CAT) format of the NCLEX that was adopted in 1994.26 The Health Education Systems, Inc (HESI) Exit Exam (E2) is one such exam.
The HESI Exit Exam
Findings published after the Carpenter and Bailey25 study indicated that the E2 is a valid and reliable measure for determining students' NCLEX preparedness.27-30 As a result, nursing faculties have increasingly turned to the E2 as a benchmark for progression. The number of students using the E2 increased from 2,809 in the 1996-1997 academic year to 25,399 in the 1999-2000 academic year, representing an increase of >800% in 4 years.29,30 The E2 is a comprehensive, computerized exam designed to be administered during the last semester or quarter of the curriculum. All HESI scores are calculated using the HESI Predictability Model (HPM), a proprietary mathematical model. HESI scores are not expressed as percentages. Instead, scores are calculated by applying the HPM to the raw score. The HPM considers the difficulty level of each test item in determining a student's performance on the exam. E2 scores range from 0 to 99.99. Students who score in the 90.00-99.99 range are predicted to pass the NCLEX without additional preparation.
Morrison et al31 first described using the E2 as a benchmark for progression. Administrators at seven nursing programs that had implemented policies using E2 scores as benchmarks for progression were interviewed regarding NCLEX outcomes before and after implementing these policies. Findings indicated that NCLEX-RN pass rates increased by 9%-41% within 2 years of implementing the progression policy. However, criteria contained within these policies, including a specific benchmark indicating readiness for graduation, were not described.
Nibert et al32 surveyed administrators of 166 RN and 36 practical nursing (PN) programs to determine the degree of risk for NCLEX failure associated with various E2 scoring intervals and to obtain information about the use of progression policies and remediation strategies among the participating schools. Their findings indicated that 45 (30.20%) of the 149 responding RN programs and 5 (16.13%)% of the 31 responding PN programs had established policies that required attainment of a minimally-acceptable E2 score for progression.
Since these findings were reported, additional data were obtained from the participating RN program administrators and from the HESI database. Therefore, this study examined the new data with the intent of expanding the original analysis reported by Nibert et al.32 Specifically, the purposes of this study were to: (1) describe progression policies established by RN schools of nursing that administered the E2 during the academic year 1999-2000; (2) identify E2 scores used as benchmarks for progression; and (3) explore remediation strategies designed to assist students in attaining the minimal E2 benchmark score as specified by their school's progression policy.
Data reported in this study were obtained from the original survey of RN and PN programs conducted by Nibert et al.32 Participation in the original study was limited to schools whose data could be successfully exported from the HESI database into the questionnaire format. A seven-item questionnaire was mailed to administrators at schools of nursing that purchased the E2 between September 1, 1999, and August 31, 2000. The population that received questionnaires consisted of administrators from 166 schools of nursing that administered the E2 to 6,300 students during the 1999-2000 academic year. The analysis for the most recent study focused on data received from the RN program administrators only. Additional data were also obtained from the HESI database regarding the participating schools' use of different versions of the E2 to retest low-scoring students.
Responses to the questionnaire were received from administrators at 158 of the 166 (95.18%) schools of nursing. These responses were based on 5,903 students' scores on the E2. Of the 5,903 students, 3,459 (58.60%) were enrolled in 92 associate degree (ADN) programs; 2,346 (39.74%) were enrolled in 63 baccalaureate degree (BSN) programs; and 98 (1.66%) were enrolled in 3 diploma programs.
Administrators at 149 (94.30%) of the 158 participating schools responded to a question regarding adoption of a progression policy, and 45 (30.20%) of these respondents reported that they had either implemented or maintained a progression policy during the study year. Of the 45 programs, 35 (77.78%) submitted either complete or partial progression policy statements from their schools. Based on a review of the submitted policies, three consequences were most often cited for students who did not achieve the benchmark E2 score designated by the school. Those consequences included denial of eligibility for graduation (18 or 51.43%), an incomplete or failing grade in the capstone course (12 or 34.29%), and/or withholding of approval for NCLEX candidacy (5 or 14.29%).
Additional data were obtained from the HESI database regarding mandatory retesting for students who failed to meet established benchmarks at the 45 schools that had adopted progression policies. In 1999-2000, 36 (80.00%) of these schools required retesting using a different version of the E2. One year later, in the 2000-2001 academic year, four additional programs required retesting for students who failed to attain the stated benchmarks, bringing the total number of schools that retested to 40 (88.89%).
Of the 35 progression policies submitted, 20 (57.14%) policies specified the number of retests allowed. Retesting was permitted only with a different version of the E2. Of the 20 schools, 7 (35.00%) permitted one retesting, 9 (45.00%) permitted two retestings, and 4 (20.00%) permitted an unlimited number of retestings. Program administrators also reported that typically their schools covered the cost of the first E2, which was either attributed to a school fee or a fixed program cost, but that students who retested were required to pay for all repeated exam administrations.
Benchmarked E2 Score Needed to Progress
Program administrators were asked if a minimal HESI score on the E2 was required for progression to graduation or NCLEX candidacy. Of the 158 participating programs, 149 (94.30%) administrators responded to this question, and 45 (30.20%) of these respondents indicated that they had established a policy that designated a specific E2 benchmark score for progression. The benchmark scores reported by these 45 schools ranged from 77 to 90. Most (36 or 80.00%) of the programs reported using an E2 score of 85 as the benchmark for progression. Seven (15.56%) schools adopted E2 benchmarks scores above 85: three selected 90, two selected 88, and two selected 87. Two (4.44%) schools chose scores below 85: one used 80 and the other used 77.
Program administrators were asked if remediation was required as a function of the school's progression policy. Of the 158 participating programs, 149 (94.30%) submitted responses to this question. Most program administrators (107 or 71.81%) reported that remediation was not required. However, these administrators described optional remediation plans available to students who did not meet the minimal E2 requirement for progression. The optional remediation strategies used were the same as the required strategies reported; however, no consequences were involved if students failed to complete the remediation activities. Of the 42 (28.19%) schools that required remediation, the strategies implemented were: a specially-designed remediation course (22 or 52.38%); completion of computer-assisted instruction programs (10 or 23.81%); a comprehensive review guided by NCLEX preparation books (4 or 9.52%); participation in mandatory tutoring sessions with faculty (4 or 9.52%); completion of an NCLEX simulation exam (1 or 2.38%); and reenrollment in core nursing courses (1 or 2.38%). Figure 1 describes remediation strategies used by the participating schools.
|Figure 1. Remediation strategies used by participating programs.|
Discussion and Recommendations
Benchmarking for progression to graduation and NCLEX candidacy has emerged as a new trend in nursing education. According to Nibert et al,32 approximately one-third (45 or 30.20%) of the 149 responding RN programs indicated that they had implemented a policy that used HESI scores on the E2 as a benchmark for progression, while only one-sixth (5 or 16.13%) of the 31 responding PN programs had implemented this type of policy. The authors also reported that the risk for NCLEX failure of low-scoring PN students was significantly greater than that of low-scoring RN students.32 Based on this current, more extensive analysis of the frequency data obtained from the survey conducted by Nibert et al,32 it is conceivable that that the lower risk for NCLEX failure experienced by the RN students as compared to the PN students could be related to the greater use of progression policies among the RN programs. Further study is needed to determine the direction of this new trend among all types of nursing programs and to evaluate the effectiveness of these policies in reducing the risk of NCLEX failure.
Between 1999 and 2001, most (88.89%) of the participating program administrators that had implemented progression policies retested students using a different version of the E2 following the required remediation. This finding indicates that programs are not only increasingly adopting progression policies that require attainment of a specific E2 score, but that they are also evaluating the effectiveness of the remediation strategies implemented through retesting.
Benchmarked E2 Score Needed to Progress
The overwhelming majority (80.00%) of the administrators who adopted a specific E2 benchmark for progression chose a HESI score of 85 as the minimally-acceptable score. Nibert et al32 indicated that 98.30% of the RN students who achieved HESI scores between 90.00 and 99.99 and 94.08% of the RN students who achieved HESI scores between 85.00 and 89.99 were successful in passing the NCLEX on their first attempt. Those findings were based on scores obtained from students in associate degree, baccalaureate degree, and diploma nursing programs who took the E2 for the first time.
Although the findings of the current study, as well as those of Nibert et al,32 substantiate the merit of choosing a HESI score of 85 as a benchmark for progression, other factors should also be considered. The first consideration must be the number of times the student re-tests with different versions of the E2 before achieving the minimally acceptable benchmark score. Remediation efforts are likely to render students who require multiple attempts to achieve the desired E2 benchmark better prepared for NCLEX than they would have been without such remediation and retesting. However, they may still be at greater risk for NCLEX failure than those who attain the benchmark score on their first attempt. Further research is needed to establish the specific degree of risk for NCLEX failure associated with the number of times students are allowed to retest with different versions of the E2.
As reported by Nibert et al,32 another factor to be considered by faculties contemplating the adoption of a minimal E2 score for progression is the size of the graduating class. Programs graduating few students can tolerate less risk of NCLEX failure. In small programs, annual pass rates are adversely affected by even one failure, thereby placing these schools at risk of losing accreditation or receiving greater scrutiny by the state board of nursing. Therefore, faculties with small graduating classes may want to choose a more conservative approach by selecting a higher E2 benchmark score than schools with larger numbers of graduates. Future research is needed to establish the degree of relationship among class size, E2 benchmarks, and NCLEX outcomes.
Remediation interventions described by the participating administrators were typical of those previously identified in the literature.9-10,12-13,16 However, one important new trend was confirmed: schools have begun to tie the completion of remediation to the approval for graduation or NCLEX candidacy for students who fail to attain specified E2 benchmarks. This trend validates the conclusions reported by Morrison et al,31 who stated that progression alone was enough to motivate students to study so that they would meet designated E2 benchmarks, ultimately becoming prepared to pass the NCLEX.
Assisting students to complete the nursing curriculum and helping new graduates become successful first-time NCLEX-RN candidates have always been high priorities for nursing faculties. However, the recruitment of more diverse populations into nursing has made these goals more difficult to achieve. Such recruitment has both positive and negative effects. Undoubtedly, academically at-risk students are provided educational opportunities that might not have otherwise been available to them. However, nursing faculties may also face higher attrition rates and decreasing NCLEX pass rates as a result of these efforts to increase enrollment in nursing programs. The findings of this study indicate that the use of E2 scores as benchmarks for progression was effective in providing a guide for remediation, which enabled faculties to better assist students to complete the nursing curriculum and become successful NCLEX candidates.
The authors thank Dr. Susan Morrison, President, Health Education Systems Inc. (HESI), for granting approval for use of the HESI database, the program administrators who responded to the HESI questionnaire, and Donna Boyd for her editorial assistance with the manuscript preparation.