1. Spurlock, Darrell Jr. MS, MSN, RN

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I write to point out several concerns about the article "Decrease New Graduate Nurse Orientation Costs by Using HESI Exit Exam Scores."1 First, the title seems to indicate that the article was about decreasing the cost of orienting newly graduate nurses. However, there were no data or discussion about how the use of the Health Education Systems, Inc (HESI) Exit Examination (E2) reduces orientation costs. Also, interpreting study findings is difficult because there was no validity evidence provided on the main instruments in the study except for the E2.


Next, the authors noted that those who scored above 90.0 on the HESI E2 were predicted to pass the National Council Licensure Examination (NCLEX). Forty-nine of the 108 nurses scored above this cutoff score, and all passed the NCLEX on the first attempt. Five low-scoring nurses failed the NCLEX on their first attempt. In the calculation of accuracy, the authors did not account for the 54 nurses who scored between 80 and 89.99 who passed the National Council Licensure Examination-Registered Nurse (NCLEX-RN). The E2 is incorrectly interpreted to be 100% accurate in predicting NCLEX-RN success. There are accepted ways to calculate the accuracy of any test that classifies test takers into categories. Evaluating educational tests using this model is neither new2 nor uncommon.3,4 This model has been applied to the E2.5-7


Lastly, the authors claim that the E2 is designed to evaluate "new graduate nurses' ability to function as entry-level nursing professionals."1(p462) However, according to the founder of HESI, "The E2 [Exit Exam] was developed to assess students' preparedness for the licensure exam."8(p220) Clearly, only the NCLEX is designed to evaluate a newly graduate nurse's ability to function as an entry-level nurse. Until further evidence can be produced which clearly shows that the E2 has incremental validity beyond the NCLEX-RN, its usefulness in service settings is questionable.




1. Reiter MA, Young A, Adamson C. Decrease new graduate nurse orientation costs by using HESI Exit Exam scores. JONA. 2007;37(10):459-463. [Context Link]


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3. McGlinchey MT, Hixson MD. Using curriculum-based measurement to predict performance on state assessments in reading. School Psych Rev. 2004;33(2):193-203. [Context Link]


4. Fuchs LS, Fuchs D, Compton DL, Bryant JD, Hamlett CL, Seethaler PM. Mathematics screening and progress monitoring at first grade: implications for responsiveness to intervention. Except Child. 2007;73(3):311-330. [Context Link]


5. Spurlock D, Jr, Hanks C. Establishing progression policies with the HESI Exit Examination: a review of the evidence. J Nurs Educ. 2004;43(12):539-545. [Context Link]


6. Hanks C, Lauchner KA. How well does a test predict an outcome? Comput Inform Nurs. 1999;17(3):120-125. [Context Link]


7. Spurlock D, Hunt L. A study of the usefulness of the HESI Exit Exam in predicting NCLEX-RN failure. J Nurs Educ. In press. [Context Link]


8. Morrison S, Adamson C, Nibert A, Hsia S. HESI exams: an overview of reliability and validity. Comput Inform Nurs. 2004 07;22(4):220-226. [Context Link]