The Bureau of Labor Statistics1 projects that new jobs in nursing will increase by 29.4% between 2004 and 2014. Health Resources and Services Administration (HRSA)2 projects that the nation's nursing shortage will grow to more than 1 million nurses by the year 2020 and reports that to meet projected growth in demand for RN services, United States nursing programs must graduate approximately 90% more nurses than they are currently graduating. Unprecedented recruiting efforts have been initiated that are designed to bring new applicants into college and university nursing programs, and they have offered some abatement to the persistent nursing shortage in the United States. However, the shortage of qualified nursing faculty to teach the increased number of applicants has created a new type of nursing shortage, one that has abruptly stifled the temporary relief offered by rising enrollments. The American Association of Colleges of Nursing (AACN)3 reported that enrollment in entry-level baccalaureate nursing (BSN) programs increased by 7.60% in 2006 over the previous year. However, the AACN also reported that 42,866 qualified applicants were turned away from baccalaureate and graduate nursing programs in 2006. Of those who participated in the 2006 AACN survey, 71% identified faculty shortages as a reason for not accepting all qualified applicants into entry-level nursing programs. Furthermore, the AACN4 projected an 8.8% nursing faculty shortage for the 2007-2008 academic year. Based on data obtained from a national survey of nursing schools conducted in 2006, Malone,5 chief executive officer of the National League for Nursing, testified before the United States House of Representatives and estimated that the number of budgeted, unfilled, full-time nursing faculty positions in the United States was 1390, which represented a 5.6% nursing faculty vacancy rate in associate degree nursing (ADN) programs. Yordy6 referred to the shortage of nursing faculty as a crisis in healthcare and reported that as recruitment efforts succeed, the demand for faculty will increase, thereby making the projected faculty shortage even worse.

The fact that large numbers of students are being turned away from nursing programs forces nursing faculty to make increasingly difficult decisions concerning their applicant pools. Specifically, nursing faculties are called upon to make evidence-based decisions when selecting applicants to help ensure that the most qualified candidates are admitted to the program. Applicants' high school and prerequisite nursing course grade point averages (GPAs) are of questionable value because of concerns about grade inflation and variable grading systems. In contrast, standardized tests exhibit greater precision and methodological rigor and thus are believed to provide a more reliable and consistent measure of students' achievement and ability. Nursing faculty whose workload is already stretched beyond capacity because of the large number of faculty vacancies need to fairly and efficiently identify applicants who are most likely to succeed in their particular undergraduate nursing program. To determine the value of HESI Admission Assessment (A²) in predicting student success, the faculty at an ADN program in Texas and the faculty at a BSN program in Tennessee designed this study, using a sample of students who were already admitted into their nursing programs.

LITERATURE REVIEW

The need for a reliable predictor of applicants' ability to succeed in a nursing program is well documented. Byrd et al7 examined academic records of students in a BSN program (N = 285) and found that the prenursing GPA was predictive of successful completion of the program. Gallagher et al8 investigated the value of reading comprehension test scores in predicting students' probability of success in an ADN curriculum (N = 121) and found that 50% of student success could be attributed to reading comprehension. Yoho et al9 used Pearson correlations to determine the relationship between ADN students' A² math and reading comprehension scores and their HESI Mid-curricular (MC) examination scores. The MC was an examination designed by HESI in collaboration with the ADN faculty to evaluate students' knowledge of the content and concepts presented in the first half of their nursing curriculum. In essence, the MC was a custom exit examination for the first half of this particular school's curriculum. The findings of Yoho et al indicated that the students' A² reading comprehension scores were positively correlated with their MC scores (P = .001). However, their A² math scores were not significantly correlated with their MC scores. Yoho et al conjectured that the lack of correlation between the students' A² math scores and their MC scores could have occurred because math questions contained on the MC were basic calculations and examinees had access to a calculator within the computer program to complete these calculations. Yoho et al also reported that the A² math examination test blueprint was changed in 2005 to include more word problems that require critical thinking in addition to the ability to calculate and recommended conducting further research to examine the predictive accuracy of the A² math examination following this test blueprint change. Hardin10 reported that the A², the HESI customized MC, and HESI specialty examinations were useful for predicting success in ADN nursing programs and that the HESI Exit Exam (E²) was useful for predicting NCLEX-RN examination success. Symes et al11 described a nursing success program designed to assist BSN students with academic difficulties (N = 94) and found a strong association between students' reading comprehension ability and their completion of the nursing program.

A nursing program's annual NCLEX-RN examination pass rate is often used as a criterion for evaluation of the program's effectiveness. Findings from several studies indicate that students who have low grades in basic science courses and clinical nursing courses are less likely to pass the NCLEX-RN examination than are those with high grades.12-14 Daley et al15 examined GPAs and standardized comprehensive examination results of senior BSN students (N = 224), using scores on the Mosby Assess Test and the HESI E², and found that the cumulative GPAs and E² scores were significant predictors of NCLEX-RN examination success. Higgins16 reported that assessment testing throughout the nursing curriculum helped lower attrition rates and increase NCLEX-RN examination success. Is it possible that data provided by an entrance examination such as the A² could assist faculty in making evidence-based decisions regarding the selection of applicants who are academically prepared to meet the challenges of a nursing program? If remediation is indicated, would it not be better to initiate individualized remediation before admission, rather than wait until the student is attempting to complete the nursing curriculum? Can preadmission assessment and preadmission remediation ultimately help improve schools' annual NCLEX-RN examination pass rates and reduce attrition? These questions provided impetus for this investigation of the relationship between A² scores and students' success in an ADN and a BSN program.

PURPOSE

Based on a review of the nursing literature, the authors concluded that there was a need to assess nursing program applicants' academic skills beyond basic math and reading comprehension. The A² assesses math; English, including vocabulary and grammar skills; and knowledge of the basic sciences-chemistry, biology, and anatomy and physiology. The A² also provides personal information such as learning and motivation styles that might be useful to students in understanding themselves. Because the A² provides data that faculty believed might be useful in predicting students' ability to succeed in a nursing program, this study was designed to assess the value of the A² in predicting student success. The specific research questions addressed in this study were: (1) Do A² scores predict student academic success in an ADN program and a BSN program as measured by the relationship between A² scores and nursing course grades? (2) Do A² scores of students who complete a nursing program differ from those who do not complete the program?

METHODOLOGY

A longitudinal, descriptive design was used to assess the value of the A² in predicting student success in an ADN program and a BSN program. The sample consisted of 286 total students, 217 ADN students and 69 BSN students who took the A² after admission to their respective nursing programs. Course grades throughout the nursing curriculum were available for 68 ADN students and 69 BSN students. At the time this study was conducted, both schools of nursing used A² scores for placement, rather than as an admission criterion. The A² was administered to students immediately after admission into the nursing program, and the findings were used to identify the students' academic weaknesses. Referrals were made to remediate these weaknesses so that students who were at risk for academic failure might obtain additional assistance and improve their chances for success within the nursing program. To protect the subjects' anonymity, students were assigned a number, and all personal information was removed before the data collection process was begun.

HESI A²

The A² is a computerized examination that was administered electronically over a secure Internet link or downloaded to the school's server, and students' results were available upon completion of each examination. At the time the A² was administered to both the ADN and the BSN students, it consisted of nine examinations. Six examinations were academically oriented: math, reading comprehension, grammar, vocabulary, anatomy and physiology, and science (chemistry and biology). The remaining three examinations were personally oriented: a learning styles assessment, a personal inventory, and a behavioral inventory.* The A² produces a percentage score on each of the academically oriented examinations as well as a composite score (A² cumulative), which is the average percentage score for all academically oriented examinations the examinee completes.+ The current psychometric properties of the academically oriented A² examinations are described in Table 1. These data include the average point biserial correlation coefficient and the average difficulty level for all test items included in each examination and the estimated reliability coefficient for each examination, as measured by the Kuder-Richardson formula 20.17

Table 1. HESI Admission Assessment, Version 1: Average Test Items' Discrimination Levels (PBCC), Average Test Items' Difficulty Levels, and Exams' Estimated Reliability Coefficients (KR20)

FINDINGS

Students' A² cumulative scores were used to assess the accuracy of the A² in predicting success in nursing school. A bivariate regression analysis was conducted to determine if A² composite scores could predict course grades in all nursing courses. In the ADN program, students' A² scores were significantly positively correlated (r = 0.253-0.442; P = .05-.01) with eight of the nine (88.89%) nursing course grades in the total curriculum. In the first level of the ADN curriculum, three of three (100%) course grades were positively correlated with A² scores; in the second level, one of two (50.00%) course grades was positively correlated with A² scores; and in third and fourth levels, four of four (100%) course grades were positively correlated with A² scores (Table 2). In the BSN program, students' A² scores were significantly positively correlated (r = 0.241-0.374; P = .05-.01) with 10 of the 20 (50.00%) nursing course grades in the total curriculum. In the sophomore year of the BSN curriculum, four of five (80.00%) course grades were positively correlated with A² scores; in the junior year, five of nine (55.56%) course grades were positively correlated with A² scores; and in the senior year, one of six (16.67%) course grades was positively correlated with A² scores (Table 2).

Table 2. Pearson Correlations of HESI Admission Assessment Scores With Course Grades and Completion of the ADN and BSN Programs

Data reported for the BSN program indicated that all 69 students who took the A² after admission into the upper division of the nursing program completed the program within 2 years of admission. A² scores were reported by four different cohorts of the ADN program, but data regarding course grades were inconsistently reported for all but one of these four cohorts. Therefore, the one cohort that consisted of 68 ADN students with reported course grades throughout the curriculum was used to analyze the relationship between A² scores and course grades. The four cohorts who took the A² after admission to the ADN program provided a total sample of 217, and 80 (36.87%) of these 217 students did not complete the nursing program within two years of admission. A two-tailed t test was used to determine if the A² scores of those who completed the ADN program were different from those who did not complete the program. The mean A² score for the four cohorts of ADN students who completed the program was 75.98, and the mean A² score for those who did not complete the program was 70.44. Findings indicated that those who completed the ADN program scored significantly higher (P < .001) on the A² than those who did not complete the program (Table 3).

Table 3. A

DISCUSSION

Although research findings continue to describe GPA in prerequisite nursing courses as a predictor of student success,7,15 scores on a standardized admission examination provide additional objective data that can be used for making evidence-based decisions about applicant selection. Such measures should be reliable and valid. The data obtained from this study indicate that the A² is a reliable instrument and that it was a valid predictor of student success in the participating ADN and BSN programs.

In the ADN program, A² scores were positively correlated with 100% of the course grades in the first, third, and fourth levels of the curriculum and with 88.89% of the course grades in the total curriculum. In the BSN program, A² scores were positively correlated with 80.00% of the course grades in the sophomore year of the curriculum and with 50.00% of the course grades in the total curriculum. As students progressed within the BSN curriculum, the number of nursing course grades that were significantly correlated with A² scores decreased. This finding is not surprising because attrition that results from academic inadequacies is likely to occur in the beginning-level courses.

The findings obtained in this study are not only relevant to nursing faculties who use or might use A² scores as a resource when making admission selection decisions, they are also valuable to individual examinees who take the A². Scoring reports provide information about an individual applicant's basic academic skills, and this information can serve as a guide to remediation so that applicants can improve their chances of success in the nursing program. Individualized scoring reports also describe the applicant's learning style and personally oriented inventories, which can assist applicants in tailoring self-guided activities that are likely to improve their chances of success in clinical nursing courses.

The cost of attrition is expensive not only monetarily but also in terms of the loss of potential graduates who might help ameliorate the current nursing shortage as well as the shortage of qualified nursing faculty. It is therefore imperative that faculty have access to reliable predictors of applicants' ability to succeed in a nursing program so that attrition might be reduced and applicants' weaknesses remediated prior to admission.

The mean A² score for the ADN students who completed the nursing program was significantly higher than the mean A² score for those who did not complete the program. Based on data obtained from this study, the faculty at the participating ADN program chose to use applicants' A² scores as a criterion for selection with future applicants to the program. All students in the participating BSN program completed the nursing program; therefore, no data existed for BSN student participants who did not complete the program. Further study is needed to determine if there is a difference in the mean A² scores for BSN students who complete the nursing program and those who do not complete the program. The findings of such a study should be compared with the findings of this study regarding mean A² scores of ADN students who completed the nursing program and those who did not complete the program. In addition, further study is needed to examine the value of using the A² as an admission criterion and to determine if there is a relationship between use of the A² as an admission criterion and attrition from the nursing program.

CONCLUSION

The increased interest in nursing as a career choice might indicate amelioration of the nursing shortage problem if it was not for the shortage of nursing faculty to teach the increased number of applicants. This faculty shortage limits the ability of nursing programs to increase enrollments. It is therefore imperative that nursing faculty seek resources to assist in the arduous task of selecting the most qualified applicants, those who have the ability to succeed in an academically challenging nursing program and become licensed upon graduation from these programs. Findings of this study indicate that A² scores are valid predictors of student success and can therefore assist faculty in the selection process as well as assist students in identifying their academic weaknesses so that these weaknesses can be remediated before they enter a nursing program. Although use of the A² will not ameliorate the nursing shortage or the nursing faculty shortage, it can enhance faculty effectiveness and efficiency and provide evidence-based data for the decisions that faculty are required to make regarding applicant selection. Nursing faculty are a valuable but limited resource, and technological advances that enable them to be more productive are extremely valuable. With the severe current nursing faculty shortage and the HRSA mandate to increase the number of graduates from United States nursing programs by 90%,2 faculty can little afford to admit students into nursing programs who are academically ill-prepared to succeed in the program.

The findings of this study indicate that the A² provides valuable information about students' academic ability to succeed in a nursing program, thereby making it a valuable tool for faculty to use in selecting applicants for the limited number of nursing student admissions. However, because the A² provides only additional objective data, it is the authors' collective opinion that it should not be used as the sole criterion for admission into a nursing program. GPAs should continue to be evaluated both quantitatively and qualitatively by assessing the numerical value, evaluating particular course grades such as science, and reviewing which institutions awarded the course grades. Considering that GPA data can be affected by grade inflation and differences in grading systems, the A² provides a worthwhile, objective measure that can enhance the selection process for nursing school admissions.

REFERENCES