Much has been written about the best way to prepare nursing students for the National Council Licensure Examination-RN exam (NCLEX). Authors agree that some form of remediation should be offered if the student fails an exit examination.1-3 Evidence of the benefits of remediation is well documented in the literature. A study by Farmer-Hinton4 found that elementary students made gains in reading and math when extra instructional time was offered. Elder and Paul,5 in their article on critical thinking, discussed the importance of teaching students how to study and learn by opening their minds to new concepts and thinking within the concept. At the community college level, Perin6^(p54) writes, "A key to effective remediation seems to build in support systems and teaching mechanisms that focus directly on student needs and interests." A study by Stewart et al7 addressed the issue of nursing students' use of learning support services. The authors found that significantly more older students independently sought out learning support, the most frequent excuse for not attending support services was time issues (ie, work, family), and students who perceived support as an empowering strategy were more likely to attend.

Where nursing authors differ is on the question of who, when, and how remediation should occur. What should be the deciding factor for who needs remediation? Is end-of-program remediation too late? What is the best way to provide meaningful remediation? When our NCLEX pass rate fell to 65%, a taskforce was formed to try to identify the problem areas and develop strategies for remediation.

NCLEX Taskforce

The School of Nursing NCLEX Taskforce determined that there were several problem areas contributing to the students' poor performance on the NCLEX exam; curriculum content for each course was not clearly defined, testing throughout the program did not always address critical thinking using application questions, students who had a history of poor academic performance were not identified early in the program as at-risk students, and there was no remediation plan in place throughout the student's program of study.

As a result of these findings, faculty developed standard curriculum grids so that each student is provided with consistent and complete content. Faculty attended test construction workshops that helped them develop higher-level questions for their courses. In addition, diagnostic computer testing programs, including course-specific exams, midcurricular, and exit examinations, were reviewed and purchased. Finally, the taskforce recommended incorporating content-specific NCLEX review questions into existing university structured learning assistance (SLA) workshops.

Structured Learning Assistance

University SLA workshops began in 1993 as a way to help students master course content and develop successful learning strategies. The program originated out of the realization that underachieving students were not using the existing academic support services on campus. Students seemed hesitant to use tutoring services and those who did were already doing well in their courses. Existing study skills courses were too generic in nature to assist the students in specific course content. Students who needed the most academic support were not receiving it because there was no mechanism in place to mandate their participation.8 Since 1993, the SLA workshops have been an efficient and economical way to reach a large number of university students who need study and learning skills. Consistent with research findings of effective remediation, SLA provides extra instruction time that a student must appropriately time-manage, teaches students how to study, and focuses directly on students' needs and interests.

The University SLA program provides 2 to 4 extra hours weekly of mandatory study and practice workshops attached to courses with a history of high failure rates. The workshops emphasize course content and teach study skills and learning strategies as they directly apply to a content area. Each workshop is facilitated by a trained paraprofessional who collaborates with the professor to develop materials to use in the workshop. Workshop activities include reviewing study guides of lecture topics, receiving homework assistance, preparing for tests, and working through exercises to develop students' note-taking and time- management skills.

SLA Rules

Specific attendance and conduct policies have been developed that provide structure and motivate participation in SLA. Each professor, with a workshop attached to his or her course, sets the average course grade for required SLA attendance. Students required to attend are only allowed 2 to 4 (depending on how many times a week the workshop is held) unexcused absences without penalty. Tardiness is defined as arriving more than 5 minutes after the scheduled time the workshop is to start. For every 3 times a student is late for the workshop session, they receive 1 unexcused absence. If the student exceeds the number of allowed absences, they are required to withdraw from the didactic course or receive a failing grade. Students who have maintained a course average above the SLA attendance requirement are encouraged to attend the workshops voluntarily but are not required to follow the attendance policies. There are also expectations for student participation in the workshop and specific rules of conduct. At the beginning of each semester, the SLA attendance and workshop policy is reviewed with the students, and they are required to sign a statement of understanding.

SLA Evaluation

The students perform an evaluation of the university SLA program at the end of each academic year. Each year, pass rates for students who attended the workshops are higher than for students in identical courses without SLA workshops. At the end of the 2003-2004 academic year, Ferris had 60 sections of SLA workshops. A majority of the students felt the SLA workshops were instrumental in their achieving a passing or higher grade. More than half of the students in SLA attended voluntarily attesting to the value of the workshops. Seventy-nine percent of the students felt facilitators were effective to very effective in conducting the workshops.

The overall cost per student to run the university SLA program is approximately $42 per class seat and is provided by either grant money or university funding allocations, so there is no additional cost to the student who attends SLA workshops. A student receives essentially free tutoring and a better chance of success in the course.

SLA for Nursing and NCLEX Review

The members of the NCLEX taskforce realized that SLA would be the perfect format for incorporating NCLEX review all 4 semesters at no extra cost to the student. University SLA workshops are now attached to the nursing pharmacology course offered the first clinical semester and the 3 medical/ surgical nursing courses offered the second, third, and fourth clinical semesters.

Because research shows that students who obtain higher grades in nursing courses are more likely to pass the NCLEX examination,9-12 students who have less than an 850 average (B) in the course are required to attend SLA. Also, at the end of the first year HESI custom exam, a score of 850 predicts a passing score on NCLEX. If a student has not achieved the 850 or higher, the student must attend SLA the following year no matter what his/her course average is. About two thirds of the students attend the workshops either because they are required to or because they want to achieve a higher course grade. In the past 3 years, approximately 110 students have gone through this program.

Facilitator Role

The professor for the course and the nursing department head identify facilitators for the nursing SLA workshops who are well-qualified nurses and skilled teachers. Once chosen, the facilitator and the professor work together as a team. After attending the weekly lecture and meeting with the professor, facilitators clarify and enhance the content covered each week and help the students develop learning strategies so they can apply the information. Being a clinically competent nurse helps the facilitator bring "real life" examples to the students, making application easier. In our medical/surgical courses, the facilitator brings equipment, forms, and case examples from the hospital setting to help the students with their hands-on learning. She demonstrates effective note-taking techniques, good study habits, and application of content. Not only does a good facilitator offer learning strategies that provide transferable skills throughout the student's academic career but he or she creates an extension of the learning environment beyond the didactic classroom. This extension includes NCLEX review questions pertaining to weekly didactic content.

Structured learning assistance workshops are divided into two 1-hour sessions. The first hour of the SLA workshop is devoted to understanding the weekly class content. For example, the week that diabetes mellitus is covered in class, the facilitator has the students work in groups analyzing the local hospitals admission physician's order form for the diabetic client. Each group has to identify rationales for each order. Discussion follows with the facilitator helping the students understand the "why" for each order, and thus, helping with the learning process.

We require students to purchase a specified NCLEX review book their first clinical semester. During the second hour of SLA, students practice answering NCLEX questions specific to the content being reviewed. The facilitator helps the students critically think through the questions by identifying rationales for right and wrong answers. Discussions that follow further enhance the learning process. Facilitators often identify students who are having difficulty applying the information and then work more closely with them or alert the professor of the at-risk student. The facilitator may also use collaborative learning by having the students work to answer NCLEX questions in groups. This is especially helpful once the custom or exit examinations have been taken, and students are aware of their areas of weakness. Groups with similar needs (eg, students who tested poorly on postnatal care) can then be formed, allowing the students to concentrate their remediation in those areas.

Conclusion

Nursing students need a systematic integration of NCLEX review. Structured learning assistance workshops can provide study skills, increased understanding of course content, and an opportunity to practice NCLEX questions. Within 2 years of implementing the NCLEX taskforce recommendations, the School of Nursing's NCLEX pass percentage went from 65% to 92%. Incorporating NCLEX review questions into the SLA workshops throughout the student's program of study played a major role in a student's success.

References