1. Thomas, Marie H. PhD, RN, CNE
  2. Baker, Susan Scott BSN, RN


Evidence-based nursing requires that students think reflectively and use clinical inquiry to develop clinical reasoning and decision-making skills. Likewise, nursing students need a strategy to be successful in passing the NCLEX-RN. The authors identify strategies based on nursing research to facilitate student success. While learning the evidence-based nursing process, the student must begin to think like a nurse while answering clinical practice questions. Using the skills taught for evidence-based nursing can be a powerful tool to approach the NCLEX-RN and succeed.


Article Content

Evidence-based nursing (EBN) requires thinking reflectively and using clinical inquiry to answer clinical questions.1 For students to be successful in passing the NCLEX-RN, they must apply these same skills in multiple-choice (MC) tests. How can faculty members help students be successful test takers? What contributes to testing errors on MC tests? As Ireland stated, "evidence-based nursing[horizontal ellipsis] uses problem solving methods to integrate the best research evidence with client preferences, values, and clinician expertise."1(p90)


New information about pacing strategies, decision trees and teaching critical thinking using EBN, active learning, and concept mapping are just a few of the new research-based initiatives. When identifying the impact of test anxiety on nursing students, studies2 found that students exhibiting high levels of anxiety had their test performance adversely affected and their ability to learn impeded. Three areas have been identified to improve NCLEX-RN performance: knowledge base, anxiety control, and test-taking skills.3 Moving students from memorization to experiential learning can also improve the student's ability to critically think.4 Individual faculty advisors are able to identify academic concerns, testing anxiety, and outside factors impeding learning ability.5 Student success on tests have been shown to be influenced by pacing strategies.6


Age, experience as a licensed practical nurse, gender, personality, and life issues were not predictors of NCLEX-RN success, whereas GPA and hours of study before the test were reliable predictors of NCLEX-RN success. Research in test taking has identified some important concepts to help nursing students be successful.


Instructors recognize that students must be prepared to take the NCLEX-RN but that the priorities for the faculty are not to teach to the test but to teach so that the student is prepared to take the test. Critical thinking has become the focal point for the NCLEX-RN.7 When the former director of the NCSBN was interviewed in 2008, she stressed that nursing knowledge will always be important but performance and priority setting have become more sophisticated.8 There are 3 areas identified in the literature to guide faculty members in helping their students be successful on the NCLEX: content mastery, test anxiety, and test-taking skills.


Content Mastery

Standardized testing and achievement examinations create a foundation for the NCLEX-RN.5(p56) Interventions that meet student needs and result in improved NCLEX-RN pass rates have been identified.9 Starting in the first semester, faculty members need to prepare students to succeed on computerized MC tests including alternative test item forms. Ireland1(93) recommended introducing EBN and the EBN process in the first semester. Students who used both strategic and deep learning approaches are more successful.9 Using the EBN process, the student can begin to reflect on practice and incrementally develop a tolerance for differing clinical perspectives, evolving from student to novice practitioner.


Strategies for improvement have included identifying the learning needs of the individual and the group using NCLEX-RN formatted examinations such as those by National League of Nursing, Mosby and Assessment Technology Institute and HESI.10-14 Interventions were to identify and differentiate areas of clear understanding and those that require further focus and testing. A useful strategy helped students evaluate their own academic strengths during each semester and encouraged them to design an individualized intervention plan, complete with strengths, weaknesses, and possible barriers to success.15,16 Implementing a test-retest process using standardized assessments allows students to create a focused review of areas identified as needing remediation. With a test-retest strategy, students can view individual improvement over the course of a semester.


Consideration for individual learning styles is fundamental in education. To help students develop skills to seek, analyze, and use information effectively, each student should complete a learning style inventory17 and identify his/her preferred learning style.18 Creating a care plan and concept map based on the students' individual learning style will help them visualize the processes needed to reach their goal of passing the NCLEX-RN. Faculty should incorporate the assessment of learning styles, adjusting teaching modalities to accommodate different learning styles, and providing tools to meet all learning styles and learning needs. Identifying and integrating their learning styles allow students to be more successful in implementing theory into practice.18(p3)


Content, as well as course, examinations that use NCLEX style questions provide another opportunity for faculty assessment of students and student self-assessment. Students should be encouraged to take computerized NCLEX-RN formatted tests at home, in the library, or at school. After answering multiple NCLEX-RN type questions at 1 sitting and scoring the questions, the student uses the results to identify content for review.3(p184)


Concept mapping or creating a graphical display of an argument structure can be another effective method of developing critical thinking skills.19 This can be an effective teaching strategy because deliberate reasoning and use of evidence are required. Another strategy is to assign weekly nursing tests of 100 questions or more from NCLEX-RN formatted question banks. Assigning questions and varying assignments prevent students from memorizing questions and avoiding the question drill.5 These strategies empower students from the beginning of the nursing program to embrace their own learning and accept responsibility for their success.


Early exposure to EBN increases reflection, critical thinking, and priority setting.1(p93) Professionals such as nurses frequently face complex situations that cannot be solved by science alone, and reflective journaling can increase one's ability to solve practical dilemmas.20 A review of the literature found that reflective practice has several positive outcomes, including integration of theory into practice, increased learning from experience, and increased critical thinking and judgment.21


Encouraging students to apply the principles of EBN practice allows students to appraise evidence, reflect on practice, and nurture habits of the mind that cultivate solutions to complex problems. Reflective journaling, reviewing content based on the NCLEX test plan, as well as using the tutorial at the NCSBN Web site can help focus students' efforts. Identifying areas of content weakness through question drill can further pinpoint areas to study. Working with groups of student using concept mapping might be another effective strategy for students.


Test Anxiety

The academic implications of test anxiety are fears associated with failing examinations or the entire program. They found that effective measures of dealing with anxiety included endurance, self-control, and self-discovery measures of stress management.2(p55) Students recognize the significance of the NCLEX-RN and may experience test anxiety about the NCLEX-RN even if they have had little test anxiety before.15(p103) To decrease test anxiety, students must understand the mind/body/spirit connection and address the need for proper nutrition, sleep, and exercise before taking tests.1(p104),2(p58),3(p185),5 A high level of anxiety can have negative consequences including inability to concentrate during study sessions, misreading questions, changing answers, blanking on questions, and having physical symptoms such as diarrhea, sweaty palms, and palpitations.2(p55) Establishing a faculty advisor and a support group of other students promoted confidence and reduced anxiety.5(p56) Other recommendations include guided imagery, meditation, visualization of the final goal, as well as daily stress management activities such as exercise, healthy eating, and adequate sleep.3(p185) Adequate preparation from the beginning of the nursing program with mandatory question practice and drill is much more productive than cramming for the examination.


Test-Taking Skills

Multiple-choice items can be written to require simple cognitive processes such as recognizing a correct answer or recalling isolated facts, or they can be constructed to activate complex cognitive states and complicated performances, including understanding, prediction, evaluation, and problem solving. Multiple-choice items that merely require recall and recognition skills are far less cognitively demanding than items that mandate the retrieval of complex, associative information (ie, declarative or procedural knowledge) from long-term memory.22 Bearing in mind that the NCLEX-RN is a cognitively demanding test, what strategies can we help our students develop?


Students who develop poor pacing or rapid guessing test-taking strategies may omit test items. Rapid guessing is not the same as "random guessing" in that it involves a strategic attempt at correctly answering the remaining items. However, rapid guessing is an extreme response state that is only activated when a pacing strategy fails. It may be that pacing involves more gradual changes over the course of an examination. It is therefore useful to consider pacing as a "trajectory" that may be linearly or nonlinearly decreasing over the course of the examination.6 Self-governing functions such as confidence, persistence, test wiseness, test anxiety, and cognitive or personal characteristics may explain examinee test-taking behaviors when taking a test.22(p211) In analyzing NCLEX-RN data, there is a clear pattern in pacing between those who pass at the 75-item group, fail at 75-item group, and are indeterminate at the 75-item group. In searching for an explanation of these group differences, many factors were considered. Using hierarchical linear modeling (Figure 1), these raw data averages demonstrate rather distinct differences in the pacing trajectories for each group.

Figure 1 - Click to enlarge in new windowFigure 1. Raw response-time trajectories for 3 examinee proficiency-level groups (N = 4045).

Examinees who are classified as clear passers at 75 items (Pass-75) have the shortest response times on average; examinees classified as clear failures at 75 items (Fail-75) have the longest response latencies. Examinees classified as indeterminate at 75 items (Indeterminate) are between those pass/fail rates of response, being somewhat closer to the clear passer group. It should also be obvious that throughout the test, all 3 groups show a decrease in their response times. Pacing or teaching students to be aware of their response time should be a consideration in teaching test-taking skills.6(p85)


The examinee's ability is a mix of his/her mental ability, the time devoted to the item, and the persistence given to finding the right solution. A correct answer is given if the examinee has sufficient ability and stays on task, working on the problem until the solution is found. An incorrect answer is more likely if the examinee shifts away from the problem and ceases to work on the task despite his/her sufficient ability.23 Students who answer incorrectly even when they possess the knowledge to answer the question are unable to parse the stem. Most often, the students' misinterpretation error occurred because they created their own question instead of answering the question that was asked.24


Faculty members need to focus on aspects of critical thinking: problem solving, decision making, and diagnostic reasoning.25 Consideration of context, including identification and appraisal of assumptions, is crucial. Students need to be taught to identify key words: exclusionary words (always, never) or prioritizing identifiers (first, initially, best). Students need to be taught to isolate the problem in the test question and identify the information needed to solve the problem, recognizing that the question is a generic question and should be separated from their own personal beliefs.26 Using the evidence-based practice process, students will incorporate critical thinking abilities, motivation toward learning, and appreciation of the role of research in practice.



Critical decision making is the basis for professional nursing and is measured by the NCLEX-RN. A major challenge of nurse educators is to prepare entry-level practitioners for successful completion of this examination by developing critical thinking and critical synthesis skills. By implementing an evidence-based plan that addresses content knowledge, test anxiety, and test-taking skills, nurse educators can promote student success. Incorporating evidence-based strategies allows nursing faculty to promote a positive learning environment with positive student outcomes.




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