1. Greenspan, Valeda C. PhD, RN
  2. Springer, Pamela PhD, RN
  3. Ray, Karen MSN, RN

Article Content

The nursing shortage prompts nursing education programs to institute creative, collaborative strategies because the shortage is expected to be long lasting and greater in proportion than any seen in the past. Nursing programs have responded by increasing the number of graduates across the country. This expansion has not been without its challenges, however, in terms of finding adequate faculty and clinical placements and delivering acceptable pass rates on the national licensing examination (NCLEX-RN).


Pass Rate Concerns Result in Assessments and a Tri-nodal Model

Pass rates trending downward to the lower 80% range, 2004-2006, concerned administrators of a Rocky Mountain nursing program and area employers. This concern led to the conduct of multifocal assessments in the fall of 2006 as a quality improvement project by a retired nursing dean acting in a consultant role. The assessments involved visits with recent graduates, class and clinical postconference visits, test review, and dialogue with employers.


Analyses of the assessments emerged into patterns synthesized into a conceptual model depicting a unique, tri-nodal model (Figure 1) to better understand NCLEX success. The model conceptually presented accountability for NCLEX-RN success by 3 components-students/graduates, program/faculty, and employers. In essence, this model conceptually posited that it takes all 3 components working together to enhance NCLEX-RN success. The model takes away the "we-they" blame or cause and effect and substitutes an attitude of "we are in this together."

Figure 1 - Click to enlarge in new windowFigure 1. Tri-nodal model for NCLEX-RN success.

Uniqueness of the Tri-nodal Model

The tri-nodal model seems unique to the literature and with its inclusion of the employer as a definitive, equal partner in NCLEX-RN success. The literature provided limited insights and strategies in addressing employer benefits as a stakeholder. Beeman and Waterhouse1 pointed out the lack of contribution to RN levels of patient care in the 90-day wait interval between a fail and a retake, which is more devastating during nurse shortages. Wray et al2 said hospital interventions to increase NCLEX-RN pass rates provided "cost savings," improved "morale," and may be related to "positive patient outcomes." Preparation for NCLEX may be packaged in marketing and recruitment enticements. Schwarz3 suggested employer actions of placing newly hired graduates in a clinical role for knowledge, critical thinking and skill acquisition; organizing small support and study groups; and enabling NCLEX-RN review.


Employer as a Stakeholder in NCLEX-RN Success

Hiring and training costs of new graduates have risen. Using inflation-adjusted methods by Jones,4 a local Rocky Mountain medical center representative estimated the hiring and training cost at $27,600. When new graduates fail the NCLEX-RN, the resultant vacancy costs increased this cost estimate to $85,197. The employer holds considerable impetus for involvement in NCLEX-RN success to avoid a 3-fold increase from orientation costs to resultant vacancy costs when new graduates fail.


Because of the expense involved in the orientation of each new employee, employers clearly have a vested interest in improving the pass rate of employees. When employees fail the NCLEX-RN, self-esteem falls along with salary, leaving both a psychological and financial price to pay. In this Rocky Mountain area, many students are employees in various capacities (especially nurse apprentices) before graduation and afterward in prelicensure status, so the employing institutions can implement strategies both before and after graduation to help with NCLEX-RN success.


Initial dialogue between the consultant and several representatives from a major employer of graduates resulted not only in recommendations for the employer but also in the recognition that the employer is a major stakeholder who benefits from active involvement in NCLEX-RN success. The dialogue involved a 2-pronged approach. The medical center representatives brainstormed about how the NCLEX-RN failures impacted them and related various strategies they had tried. The university nursing program's consultant shared recommendations synthesized from the multifocal assessments. And, as a result, changes have occurred.


Employer-Based Strategies Emanating From Nursing Program Collaboration

Recommendations, strategies, and the tri-nodal model have been shared with employers including at advisory board meetings and in special meetings with managers throughout the area. The recommendations have been actively shared by nurse educators in practice settings to elicit employer help in implementing the recommendations in their facilities.


Out of the productive initial dialogue meeting with representatives of one major employer, definitive recommendations (in italics) shared and strategies posited for implementation by the employer included the following:


* Help graduates balance orientation to their new role/job while allowing time to study for the NCLEX-RN examination. Question new graduate employees about their NCLEX-RN date, and make orientation schedule changes accordingly.


* Ask graduates about their weak areas based on assessments in school and focus on those areas in orientation. Encourage sharing with staff developers the results of the Health Education Systems Incorporated (HESI), a predictive examination taken near exit from the nursing program. Develop individualized strategies focusing on strengthening weaknesses. Make an NCLEX-RN review course available.


* Share the consequences of NCLEX failure with new employees. Enlighten new employees about the impact of role and salary changes. Indicate that repeated failures jeopardize continuing employment.


* Schedule time off for review and relaxation before the graduate takes the licensing examination. Schedule developmental days with emphasis on NCLEX review methods and test taking skills.




The program's faculty worked together initially with one major employer and later through information sharing with other employers to ensure success of the program's graduates on the NCLEX-RN examination. All of the measures taken by the major employer helped make graduates feel supported. The medical center has continued to refine initial strategies into definitive programs for new graduates.


In summary, the tri-nodal model encompasses the employer who holds accountability for a key role in NCLEX-RN success. The employer changes, when coupled with changes made by the program and faculty, have resulted in about a 10% increase in NCLEX-RN pass rates in 2007 for all of the program's graduates. The resultant pass rate was above the national average for US-educated, first-time test takers of 85.5%,5 which suggests that the tri-nodal model uniquely provides an effective conceptual basis for ongoing quality improvement.




1. Beeman PB, Waterhouse JK. Post-graduation factors predicting NCLEX-RN success. Nurse Educ. 2003;28(6):257-260. [Context Link]


2. Wray K, Whitehead T, Setter R, Treas L. Use of NCLEX preparation strategies in a hospital orientation program for graduate nurses. Nurs Adm Q. 2006;30(2):162-183. [Context Link]


3. Schwarz KA. Making the grade: help staff pass the NCLEX-RN. Nurs Manage. 2005;36(3):38,40,42-44. [Context Link]


4. Jones CB. Revisiting nurse turnover costs: adjusting for inflation. JONA. 2008;38(1):11-18. [Context Link]


5. National Council of State Boards of Nursing. Number of candidates taking NCLEX examination and percent passing, by type of candidate. January, 2008. Available at Accessed August 6, 2008. [Context Link]