Achieving a 100% pass rate on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) was a goal that seemed impossible, especially in 2021. Nursing schools were in the midst of a national pandemic and learning how to teach nursing in both face-to-face and virtual settings. If past performance rates on the NCLEX-RN were an indication of things to come, the University of West Alabama Division of Nursing (DON) could have expected a disastrous 2021 year. In 2013, the program’s NCLEX-RN pass rate fell to 74%. While it rebounded during 2014-2017 (82.4, 85, 88, and 81.6%, respectively), the nursing faculty realized there was a pattern in NCLEX-RN rates that directly correlated to their student population. Scores declined again in 2018 (77.3%).
Multi-Pronged Approach
A multi-pronged approach had to be used to help the UWA DON prepare its students for success, not only during a pandemic, but post-pandemic. In 2013, one nursing faculty member was enrolled in a doctor of education program, while the other six faculty held a Master’s degree in nursing. A focus on faculty development for young faculty was crucial, but faculty development in education was also beneficial to those who lacked the tools to understand curriculum development, test-item development, and test-taking strategies. Currently, six faculty members hold doctorate degrees with an emphasis in nursing education, while one is enrolled in a doctoral program. As faculty members were earning degrees, they were learning to use research practices and methodologies to understand and predict the habits of their students.
Located in the Blackbelt region of west Alabama, the University of West Alabama serves some of the poorest counties in the nation. Students come from educationally and economically disadvantaged backgrounds, adding a layer of complexity to a curriculum fraught with rigor and time constraints.
Students are expected to attend class, skills labs, simulation labs, and clinical labs Monday through Friday. For those who have to work to make ends meet, have children or older relatives to care for, or who are ill-equipped for the study and time demands of a nursing curriculum, the first and second semester of the nursing program may prove too much to endure. To determine student learning needs and implement initiatives to support progression and graduation from the nursing program, the faculty assessed the needs of the program’s student population and diagnosed the issues hindering progression, program completion, and passing the NCLEX-RN. They could then plan interventions that would lead to better student outcomes, implement the plan promptly, and evaluate the plan for areas of strength, weakness, and opportunities.
Program Assessment
Program assessment was key to the process. Students were having difficulty in the third semester of the nursing program. Retention of content appeared to be an issue for the fourth-semester nursing students. Foundational principles of basic care and comfort were troublesome, as were the dreaded multiple-answer questions, also known as “select all that apply” (SATA). Students in the first and second semesters appeared to have trouble understanding what the question was asking them to determine. It was evident that reading comprehension was an issue for some students.
For others, a review of ACT scores on file revealed students were not very good standardized test-takers and needed intentional practice to improve test-taking skills, not merely testing for content knowledge. If a student was repeating the nursing program, they were less likely to pass the NCLEX-RN exam on the first attempt than students who completed the program in five semesters. Finally, students needed help with goal-setting, time-management, and study skills that would allow them to progress and graduate on time. With this information on board, it was time to implement strategies to help the associate in science nursing students reach their full potential and successfully graduate from the nursing program while preparing them to successfully pass the national licensure exam.
The nursing program functions from a multi-tiered approach to engage students and monitor progress throughout the semester. Each approach is needed to provide a comprehensive and inclusive model to facilitate a culture of success in the nursing program.
Faculty-Student Mentoring
A faculty-student mentoring program was important to understand the academic and non-academic challenges that nursing students would face as individuals. Individualized action plans could be created for each student to assist in program progression. The faculty-student mentoring program requires all students entering the nursing program to be assigned to a faculty mentor. Students meet with their mentors two weeks into the semester and at regular intervals during the semester to monitor academic progress and discuss issues that may deter progression or strategies that will foster success.
Retention and Progression Methodologies
Once students have been admitted to the nursing program, student progression and retention become the focal point. Students enter the program with a multitude of life affairs – children, work, bills that need to be paid.
For these reasons and others, the nursing curriculum was infused with ways to integrate positive study habits, reiterate test-taking skills, and repeat information deemed “need-to-know.” While Faculty-Student Mentors introduce students to these habits and reinforce them as necessary, a Retention Specialist (RS) would be assigned to students who were at-risk of failing the nursing program due to class performance. Student grades were monitored closely and referrals were made to the RS when needed. Some students are assigned to a RS at the outset of the nursing program and are required to meet with the RS before the first exam to review the importance of class attendance, note-taking, study habits, and test-taking strategies.
The use of repetition throughout the program has proven to be very useful. Students are encouraged to use practice test items to prepare for examinations. Students are also encouraged to create peer study groups of no more than four students to study before the exam. Students need to understand that nursing content is to be learned and not memorized for test purposes only. Convincing students to change their study habits and teaching them how to study plays an important role in progression.
NCLEX-RN Preparation
Students who graduated from the nursing program were not always successful at passing their licensure examination on the first attempt. For some, a second attempt was needed. Finding a solution to prevent this second attempt was important to the nursing program due to the financial burden that it can place on graduates, and the real and perceived negative burden placed on nursing programs by accrediting bodies. The first-time pass rate continues to be a program outcome standard that nursing programs are measured by, in spite of the increased test anxiety seen in students today.
In 2019, the Division of Nursing found a game-changer to its preparation for licensure. The introduction of UWorld NCLEX-RN QBank as a means to create practice exams for the licensure exam was one of the most significant changes made in improving licensure scores. Initially, faculty implemented the prep system without a policy to guide student behavior. Minimal gains were noted. With the introduction of a formal policy on UWorld QBank, the nursing program’s graduates were able to earn a 100% first-time pass rate on the NCLEX-RN in 2021. The UWorld policy is housed in the NS 204: Advanced Adult Health and Critical Care course taken in the final semester. Students must complete a minimum of 2000 questions in the UWorld QBank and achieve a minimum score of 65% correctly answered questions. To achieve this goal, most students have to answer in excess of 3,000 questions.
In addition to prepping, students also needed to understand the time-sensitive nature of learned content and test-taking strategies. The nursing program fully believes that its graduates are prepared to care for patients as advanced beginners as bedside nurses. But there is an awareness that test-taking behaviors and learned content will begin to fade over time. As graduates begin to practice, their new behavior will replace learned behavior. The second critical step to licensure prep for our students was testing in a timely manner. Nursing graduates were encouraged to take the NCLEX-RN by June 15th, a date that generally falls six weeks post-graduation. Students have had their NCLEX-RN review, they have completed the prep question set as stated in the course syllabus, and they have completed a predictor on NCLEX performance. The six weeks give them more time to prepare if needed, but most are ready to take the exam when a test date is available.
Financial Support
In 2020, the Division of Nursing was awarded a grant through Health Resources and Services Administration (HRSA) to support students from disadvantaged backgrounds. Project EARN (Educating Alabama’s Rural Nurses), in the amount of $2.4 million, is dedicated exclusively to scholarships. Nursing programs add costs to college students with the purchase of uniforms, assessment tools, NCLEX preparation, and travel to and from clinical sites. Many UWA students are nontraditional and/or from disadvantaged backgrounds. Alleviating the financial stress of getting a college degree has allowed students to focus on studying and graduation.
For the UWA DON, a multifaceted approach to program progression and completion has always been necessary. The mystery lay in passing the NCLEX-RN on the first attempt. The addition of a prep tool for licensure has proven to be a game-changer for nursing students. As 2022 nursing students gear up for the licensure exam, the policy is in place and UWA nursing faculty are anxious to learn if they have found the key to NCLEX success for their program.
For most nursing students, passing the NCLEX is their top post-graduation task. Once they have that exam under their belts, they become a registered nurse and can move forward on their career path. Many students study on their own using various methods and approaches, but this study shows clear benefits between more HESI exams taken and a better outcome on the HESI Exit Exam and on the final NCLEX-RN exam.
According to Christine Gouveia, PhD, vice president of Applied Learning Sciences at Elsevier and visiting professor at the University of Pennsylvania, the findings help educators and students prepare more efficiently and effectively for the NCLEX. “HESI exams span a nursing program and curriculum and are an excellent indicator of student progress on their academic journey,” she says.
Preparation with HESI exams offer multilayered benefits as nursing students gain knowledge and confidence from the testing, preparation, and remediation tools offered with HESI specialty exams and results. As students progress through different exams, they answer questions that are designed to closely resemble the questions on the NCLEX, so they can apply their knowledge in a practical way and demonstrate their critical thinking skills, says Gouveia. Those tools are helpful as they finish school and begin their careers. “Clinical judgment is critically important,” says Gouveia. “Critical thinking is necessary for nurses to practice safe effective care.”
The HESI specialty exams are an important tool for educators as well. Educators analyze the individual and cohort results to help students identify weak areas where they can use some additional work. They are able to work on remediation quickly using quizzes and case studies to synthesize their knowledge effectively. The scores also reveal students’ strengths and give them an indication of where they are excelling in their studies and can help them stay focused and motivated. Coaching support is also available to students to help them navigate challenges and to reflect on what and how they are learning and how to gain the most from their nursing education.
The results of the latest study mirror previous findings from a smaller sample size. Student success is more easily predicted when students score a 900 or greater on the HESI Exit Exam, says Gouveia. Those students are 96.4% to 99.2% likely to pass the NCLEX-RN. The study found, for example, that a student who took six specialty exams scored on average 29 points higher than those that did not take any. Completing 12 HESI Specialty Exams translated into an average gain of 160 points.
Gouveia says the study results have been translated into effective evidence-based tools using data to create predictive algorithms and interpret the results on the HESI® Readiness for NCLEX®Dashboard. The data allows educators and teams to monitor results and trends throughout a program and make real-time adjustments to benefit students as much as possible.
The last hurdle a new nursing school graduate must clear before he or she can practice as a nurse is often the most stressful one: taking the NCLEX-RN®. This licensing examination, developed by the National Council of State Boards of Nursing, Inc. (NCSBN), makes it official: Pass “the boards” (as the exam is familiarly called) and you become an RN.
This grueling, five-hour test of entry-level nursing knowledge and skills can be an intimidating experience for any new graduate. But some minority nursing leaders have voiced concerns that the NCLEX-RN playing field may not be level when it comes to students of color, especially if they were educated outside the U.S. Others dismiss these claims, arguing that the exam is indeed culturally sensitive and unbiased. Either way, strong feelings seem to arise when the subject of the NCLEX comes up.
Charlotte Richmond, RN, PhD, scientific director of anesthesia research at Mount Sinai Medical Center & Miami Heart Institute and an adjunct professor at the College of Health and Urban Affairs at Florida International University, believes that language barriers can sometimes hinder minority and international students taking the NCLEX.
“Here in Miami, the cultural diversity is very great,” says Richmond, who is part Cherokee Indian. “South Florida, particularly, has influences that come from the Caribbean Islands, Central and South America. The majority of international students who are attending the local nursing schools are having a difficult time passing the NCLEX, and it perhaps could be due to language problems.”
Americans use different terminology that international students might not know, Richmond explains. She likens it to the variations in word usage between America and England. “In that sense, the NCLEX questions are based on the American culture and not necessarily [other languages or cultures],” she adds.
Graciela Reyes, RN, BSN, CRRN, a member of the Dallas Chapter of the National Association of Hispanic Nurses (NAHN), agrees. “The [international] nurses’ difficulty is not with the content [of the test] but with the language,” says Reyes, a native of Mexico. “The medical terminology is not that much of a problem, because most of it is very similar in English and Spanish. What gave me the hardest time was the day-to-day English.”
Back in 2001, Jodi Gooden, RN, BC, PhD, an assistant professor in the College of Nursing at the University of Oklahoma, wrote an article for Minority Nurse about culturally biased classroom testing. She believes this same problem persists today. “I see it here where I teach,” says Gooden, who is part American Indian. “What I see today for some minority students is that there is a difference in their language.”
Gooden believes this issue could affect minority nursing students’ performance not just on classroom tests but also on the NCLEX–a situation that she finds particularly unfortunate. “I hate to see students put in a position where they are very knowledgeable in a clinical area, yet because of the NCLEX [and potential cultural barriers] they are limited in whether or not they can become a nurse.”
A Question of Culture
Language isn’t the only issue cited by those who feel minority and/or international nursing graduates may be at a disadvantage when taking the NCLEX-RN. “Some people don’t believe that cultural differences can be a problem,” says Richmond. “I have taught in three different states and the cultural diversity is different in each one. Language is part of [the potential difficulty for minority students], but the culture is another part of it.”
Jacqueline Crespo Perry, RN, BSN, president of NAHN’s Houston Chapter, agrees that culture can influence what minority nursing students learn. Perry has three nieces who are planning to go to nursing school. “One of them is really deep into her Hispanic roots and it is going to be a little hard for her to adjust to a lot of things she will encounter in her nursing courses,” she says. “The other two will swing right through.”
For example, Perry explains, traditional Hispanic families’ view of health care emphasizes treatment of illness rather than disease prevention. This cultural orientation can affect the way some Hispanic candidates may interpret and respond to questions on the NCLEX.
“When they read a question about children’s health, they are focusing on the illness. They look for the sick child and how you will treat that child,” Perry says. “But because the majority culture emphasizes preventing the child from getting sick, this would not be considered the ‘right’ answer.”
To cite another example, she continues, mental illness is considered a stigma in Hispanic culture. As a result, it is often not talked about, treated, or even taught in some international nursing programs. That knowledge deficiency, which can impair nurses’ performance on the psychiatric section of the NCLEX, needs to be addressed as well, Perry maintains.
In addition, the exam’s multiple-choice format can pose problems for international students, according to Cora Munoz, RN, PhD, an associate professor at Capital University in Columbus, Ohio. A native of the Philippines, Munoz is also a reviewer for the NCLEX-RN at the Kaplan Review Center in Columbus.
“I will not go so far as to say the test is not culturally sensitive,” she comments. “But I think that foreign graduates do have a problem, not so much with content but with format. Multiple choice is not a common testing format in other countries. The format itself becomes problematic.”
In Mexico, nurses take their licensing exams orally in front of a panel of judges, Reyes points out. “Then you come here, and it’s multiple choice and done on computers.”
Narrowing the International Gap
On the other side of the argument, Barbara Nichols, RN, MS, DHL, FAAN, chief executive officer of the Commission on Graduates of Foreign Nursing Schools (CGFNS), believes the NCLEX-RN is culturally sensitive. The CGFNS has a certificate program that internationally educated nurses must complete before they can sit for their boards in some U.S. states. Currently, 36 states have this requirement.
Nichols, who is African American, says the National Council of State Boards of Nursing has put many safeguards in place to ensure the testing process is fair to everyone. “The NCLEX is testing minimal knowledge,” she asserts. “It is not a test of excellence. It is a test of basics.”
The CGFNS, a private, independent, non-profit organization, was created in 1977 at the height of a severe nursing shortage that had prompted many hospitals to import nurses from the Philippines and other countries to fill their staffing gaps. “At that time, only about 15% to 20% of these nurses educated outside the United States were passing the NCLEX-RN,” Nichols explains. “This was really a big dilemma. You had all of these foreign nurses coming in but not passing the licensing exam.”
Today, statistics from the NCSBN clearly show that CGFNS’ efforts have made a difference. In 2001, out of 8,613 foreign-educated candidates taking the NCLEX-RN for the first time, nearly half (49.4%) passed the exam. But a considerable gap still needs to be closed: The first-time pass rate for U.S.-educated candidates is 85.5%.
International nursing graduates earn their CGFNS Certificate through a three-step process: a credentials review of their foreign education, registration and licensure; the CGFNS Qualifying Exam, a one-day test of nursing knowledge; and the Test of English as a Foreign Language (TOEFL), an English proficiency exam.
Passing the Qualifying Exam, says Nichols, is a good predictor of who will pass the U.S. licensing exam. Fifty percent of the nurses who take the Qualifying Exam pass it, she reports; of that 50%, 90% pass the NCLEX. Those who fail the CGFNS exam receive a letter explaining their score and indicating the areas that need to be improved.
Despite this success rate, not all advocates for international nurses are enthusiastic about the CGFNS Certificate process being linked with the NCLEX. Perry believes it is another obstacle for international nurses. Test fees and translation costs are significant, she points out. If foreign credentials to be reviewed by CGFNS are not written in English, nurses must have them translated and pay for it themselves.
Reyes, too, feels the CGFNS Qualifying Exam is an extra step that international students shouldn’t have to face before taking the boards. “If CGFNS is saying foreign nurses and U.S. nurses are equally educated, why are they holding international nurses to a higher standard?” she argues.
The NCSBN Responds
What does the National Council of State Boards of Nursing have to say about all this?
“The [NCLEX-RN] includes effective checks to minimize the potential for bias due to culture, gender and other background factors,” NCSBN maintains. “It is important that each [question] development panel is composed of nurses representing each region, a variety of practice areas, and minority populations. . .
“Differential item functioning (DIF) is the statistical approach [we use] to determine potential bias. [Questions] flagged for high levels of DIF are reviewed by a group of trained sensitivity reviewers, consisting of at least five members: one male, one representative of three of the ethnic focal groups of NCLEX examination candidates, one member with prior experience on a DIF Review Panel [and] one member with a linguistic background. . .The panel’s recommendations are forwarded to the Examination Committee for final disposition of the items. Additionally, judgments of trained individuals are used to screen [questions] for potential bias.”
In addition to the numerous content reviews conducted by the NCSBN and its member boards of nursing, the National Council also does two formal reviews looking exclusively at issues of cultural sensitivity, adds Casey Marks, PhD, director of NCBSN Testing Services.
When asked if he believes minority nurses may have more trouble passing the NCLEX than their majority counterparts, Casey answers: “We have no reason to suspect that individuals of the same ability level have anything but equal opportunity to pass the examination at the same rate, regardless of their cultural, ethnic, linguistic or racial background.”
Strategies for Success
The current debate about whether or not the NCLEX-RN is a culturally sensitive, equal opportunity exam is unlikely to be resolved any time soon. But regardless of where they stand on the issue, many minority nursing leaders believe there are steps that nursing students of color and internationally educated nurses can take to maximize their chances of successfully passing the boards.
Munoz advises international candidates to take NCLEX review courses, such as those offered by Kaplan, to gain experience in how to take multiple choice tests and to practice taking exams on a computer. Kaplan’s test-prep centers provide all candidates with test-taking strategies, she says, “but if you have international graduate nurses, probably my recommendation is to spend even more time in this area and maybe on how to handle anxiety when taking a test.”
Lilianne Cooper, RN, BSN, a member of the National Association of Hispanic Nurses, passed the NCLEX in August 2002. She agrees that preparation is crucial. “I started studying for the exam months in advance,” Cooper recalls. “The way they format the questions, you could be looking at four correct answers and your job is to pick the best one for that particular scenario. It’s the most frustrating kind of question I’ve ever had to work with.”
A recent graduate of Boston College’s William F. Connell School of Nursing who now works on med/surg floors at Brigham and Women’s Hospital in Boston, Cooper says nursing school helped prepare her for the NCLEX experience. “I received the tutoring and support I needed to help me tackle those questions,” she explains. “I basically had to learn how to answer these types of questions from scratch.”
Cooper also bought a NCLEX-RN review book with a computer CD included. “I encourage all nursing students to invest in some kind of computer review to get the feel for the computer format,” she says. “The one I purchased gave me the opportunity to take 100-question practice tests that were timed.”
Many international candidates must take English language courses before they can sit for the TOEFL. To address this need, Perry and Reyes, through the NAHN chapters in their respective cities, each run programs designed to help immigrant nurses from Spanish-speaking countries strengthen their English and other skills they need to obtain U.S. licenses.
Currently, some 42 nurses are taking English classes at the University of Houston through Perry’s program, which is called Nurses Helping Nurses. In Dallas, Reyes has set up a volunteer program in the Veterans Affairs North Texas Health Care System, where she works as a nurse educator. Internationally educated nurses who have not yet taken the NCLEX volunteer in the system’s hospitals, gaining the opportunity to work on their English with other nurses, doctors and patients. Reyes meets with the volunteers at lunch most days to discuss any language problems they may be facing.
The Dallas Chapter of NAHN also provides nursing review courses and helps candidates prepare for the NCLEX. The Houston program assists nurses who fail to pass the CGFNS Qualifying Exam by sending them to a local college to take a refresher class in the areas of nursing in which they scored poorly.
Licensing Has a Price
Many of the experts interviewed for this article believe there is still another area in which the NCLEX-RN playing field is not level: the costs associated with taking the exam. “For those in the minority community who may not be in the same socioeconomic bracket as majority candidates, there could be some disadvantages,” says Cooper. “First of all, [the cost of] taking the NCLEX alone is $300. Then on top of that, if you want to prepare for the test, you have to buy a review book and/or go to a review course. Either way, it’s more money out of pocket.”
Casquese Chaffin, RN, MSN, MA, a member of the Los Angeles chapter of the National Black Nurses Association, agrees that the cost of review courses could be a barrier blocking some minority students’ access to the licensing exam. She believes the foundations of large companies should be targeted to help foot the bill for such courses.
“These companies target their endowments [to causes] where they can ,” she contends. “It isn’t popular [to spend money] on review seminars for nurses. They won’t get a handshake for that. Until the minority community itself makes some noise–yells, screams and hollers–that won’t change.”
Money can be a big issue for international candidate as well. Munoz calls it the single biggest obstacle for nurses emigrating from the Philippines to the United States. Many Filipino nurses go to Faipan, a U.S. territory near Guam in the Pacific, to take the NCLEX exam before they come to America, and that travel represents an additional cost.
Perry’s Nurses Helping Nurses program is working to help immigrant nurses offset the costs of getting their credentials translated for CGFNS review, which can run as high as $70 per page. “We have found people who have been able to translate for us at a low cost,” she reports. “But you have to be careful. If CGFNS doesn’t think the translator is an acceptable source, they will send it back.”
Cooper thinks some minority students may not be aware of cost-cutting options available to help make the NCLEX process more affordable. “Every little bit helps,” she says. “I believe there are some [nursing employers] that offer reimbursements after new nurses take their boards and get their license. Whether it’s buying a used review book, spending an extra hour after seminar with your professor or even inquiring about a reimbursement at the hospital you applied to, it’s all more than worth it in the end when you get that license in the mail.”
Editor’s Note: This is the first in a series of articles examining leadership development initiatives at minority nursing associations.
Although she seems to juggle her dual roles with expert finesse, Susan Castor, MSN, RN, CCRN, president of the New Jersey chapter of the Philippine Nurses Association of America (PNAA) and director of patient care services for a post-coronary care unit at Community Medical Center in Toms River, N.J., remembers a time when she actually felt somewhat timid in a leadership position. Castor attributes her newfound assertiveness in part to skills she learned at the PNAA’s Chapter Leadership Institute.
“The Institute gave me the opportunity to meet and work with other nursing leaders from across the country, which was an empowering experience,” she says.
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This summer will mark the fourth year the PNAA will hold the Institute (formerly known as the Chapter Leadership Development Workshop) as part of its annual national convention. The 2007 Institute, to be held on July 11 in Anaheim, Calif., is open to the presidents and presidents-elect of each of the association’s 37 local chapters. The PNAA currently boasts approximately 4,000 members nationwide.
“We wanted to offer our chapter presidents an orientation tailored to our organization’s mission and vision,” says Reynaldo (Rey) Rivera, MA, EdM, RN, CCRN, CNAA, BC, ANP, former co-chair of the PNAA’s Education Committee and director of nursing and special programs at New York Presbyterian Hospital/Weill Cornell Medical Center in New York City.
Rivera, who is an accredited trainer in Stephen Covey’s “Seven Habits of Highly Effective People,” based the PNAA program on concepts he learned as a chapter advisor for the American Association of Critical-Care Nurses.
“Our Institute offers training in skills that benefit our chapter leaders both personally and professionally,” he explains. “In addition to learning how to recruit and retain new members, we teach [leadership skills such as] empathetic listening and relationship building.”
Expanding the Focus
After gathering feedback from past participants, the PNAA recently decided to expand its leadership training initiative. This year, the newly renamed Chapter Leadership Institute will cover five critical areas: communication, member retention/ recruitment, education, accreditation and clinical issues. Perry Francisco, RN, MSA, PNAA Education Committee chair and manager of physician education for Sentara Healthcare in Norfolk, Va., will coordinate and direct the 2007 Institute, whose theme is “Back to Basics for a Stronger Foundation.”
“We developed a curriculum that we believe will be helpful to leaders who have undergone the training in past years as well as those who are taking it for the first time,” Francisco says. “Part of the training includes a discussion of best practices. Our leaders also have the opportunity to meet with their peers and discuss how they oversee activities in their respective chapters.” PNAA national president Rosario-May Mayor, RN, MA, director of performance improvement at the James J. Peters VA Medical Center in Bronx, N.Y., says the Institute helps PNAA chapter presidents build skills that aren’t typically taught in nursing school.
“Our chapter presidents come from a variety of clinical backgrounds,” she notes. “Some are staff nurses, others are supervisors. While many have undergone leadership training, others have not.” Mayor has noticed that the PNAA chapters operate more consistently since the leadership training was first offered four years ago. She credits this to workshops on topics like developing bylaws and reviewing rules of the organization.
“The Institute offers a terrific opportunity for our chapter presidents to hone their leadership skills while also brainstorming ideas on topics such as fundraising, recruitment and retention,” she says.
“We are particularly excited about one of our presenters this year,” Mayor adds. “Sumi Haru, a former officer of the Screen Actors Guild, will present the communication piece. She will focus on the art of public speaking and presenting oneself in public—how to articulate well and engage the audience.”
Cultivating Future Leaders
Mayor is one of thousands of nurses from the Philippines who migrated to the United States in the 1960s and ‘70s. Today, in response to the current nursing shortage, U.S. medical facilities are continuing to recruit large numbers of nurses from the Philippines to fill staffing gaps.M
Today’s new immigrant nurses face a more complex health care system and stricter immigration rules than their counterparts of 30 or 40 years ago. The PNAA chapters strive to help this new wave of nurses arriving from the Philippines and provide support as they adjust to life in a new country. “The goal of PNAA is to meet the professional and personal needs of Filipino nurses across the United States and to provide mentoring activities for migrating nurses from the Philippines as well as new nursing graduates,” Mayor says.
While the PNAA is working to establish a formalized national mentoring program, many of the association’s chapters currently offer informal mentoring activities and acculturation classes to help recent immigrant nurses make a smooth transition into their new lives and jobs.
Even seasoned nurses like Susan Castor have reaped the benefits of having mentors within the PNAA organization. “Going back to school and achieving my master’s degree was one of my biggest accomplishments,” she says. “I hadn’t considered the possibility of attaining my master’s in nursing until I spoke with some of my PNAA colleagues. Their support and encouragement was invaluable.” In turn, Castor now makes it a priority to reach out to other Filipino nurses about the many benefits of PNAA membership. “Recruiting new members to PNAA is a way to secure future nursing leaders,” she says. “PNAA has not only allowed me to foster many new connections but to also reconnect with several of my former nursing school classmates [from the Philippines].”
Mayor says part of the PNAA’s mission is to emphasize the need to orient foreign-born nurses to the American health care system as well as the need to help America’s majority population increase its understanding of ethnic minority groups in today’s increasingly multicultural nursing workplace. “It’s important to dispel myths,” she emphasizes. “For example, many nurses don’t realize that a large number of Filipino nurses are U.S. citizens. We see part of our role at PNAA as promoting positive images of Filipino-American nurses.”
PNAA Celebrates Decision to Bring NCLEX® Testing to the Philippines
The Philippine Nurses Association of America (PNAA) serves as a bridge between Filipino nurses in the United States and their colleagues in the Philippines. “We promote a culture of excellence and education in our activities,” says PNAA president Rosario-May Mayor, RN, MA. “We work with the motherland on a variety of initiatives.”
This year, PNAA leaders are rejoicing in the news that thousands of nurses in the Philippines who hope to work in America will no longer have to travel abroad to take their U.S. licensing exams. On February 9, the National Council of State Boards of Nursing (NCSBN) announced that it had selected Manila, the capital city of the Philippines, as a new international site for administration of the National Council Licensure Examination (NCLEX). The test center in Manila—the first of its kind in the Philippines—is expected to open in mid 2007.
“This is excellent news for Filipino nurses and the nursing profession as a whole,” says Mayor.
Passing the NCLEX is essential for obtaining a nursing job in the United States. Up until now, due to the lack of a test site in the Philippines, Filipino nurses had to go to places like Hong Kong, Seoul or Saipan (one of the Northern Mariana Islands) to take the exam, paying hundreds of dollars in travel costs out of pocket. And that was in addition to paying the required exam registration fee.
“When Philippine nurses travel to Hong Kong or Saipan to sit for the NCLEX exam, their dollar layout may be anywhere from $1,200 to $1,500,” Mayor explains. “In addition to the $350 registration fee, examinees have to pay $500-$600 for airfare, plus pay for a hotel room, food, etc. And if the nurse fails the exam—which is a distinct possibility—he or she has to travel back there again in six months to retake it.”
PNAA leaders were actively involved in helping to make the idea of a NCLEX testing center in the Philippines a reality. Their advocacy efforts began five years ago, at a time when the NCSBN was looking into the possibility of offering the licensing exam outside the U.S. and its territories for the first time. (The NCLEX has been offered internationally since January 2005.)
“In 2002, the PNAA first approached the NCSBN with the idea of offering the NCLEX in Manila,” Mayor says. “It seemed logical that Manila [should] be among one of the pilot areas outside of the U.S. to offer the exam, since Filipino nurses make up between 50% to 60% of examinees worldwide.”
According to the NCSBN, approximately 25,518 Filipino nurses holding combined immigrant visas and work permits traveled to the U.S. to work between 1988 and May 2006. Mayor says the number of Filipino nurses taking the NCLEX-RN® was over 9,000 (35% of total examinees) in the 1990s, and more than 15,000 (60%) in 2006.
Initially, the NCSBN had some serious concerns about Manila’s suitability as a test site. There were worries about political instability, exam security issues (software piracy is a major problem in the Philippines) and the recent proliferation of inferior-quality “diploma mill” nursing schools that were churning out thousands of poorly prepared graduates to meet the huge demand for Filipino nurses in the United States.
PNAA leaders—including Mayor, past president Filipinas Lowery and president-elect Leo-Felix Jurado—worked as part of a coalition of U.S. and Philippine organizations that helped address these concerns. Some of the other groups involved in these efforts were the Philippine Nurses Association (PNA)—the PNAA’s counterpart in the homeland—and the Manila-based Commission on Filipinos Overseas, which has been working with the Philippine government to improve some of the conditions that had originally raised red flags.
The PNAA, too, is working to help ensure the continued flow of only qualified and well-trained nurses from the Philippines into the American health care system. In a recent interview with the Philippine News, Mayor expressed her disappointment about the controversial results of last summer’s Philippine nursing board exams , where it was discovered that test questions were leaked to some students prior to their taking the exam. She is also concerned that the passing rate for the Philippine board exam is still alarmingly low—only 42%.
“It is an embarrassing percentage and tends to mirror the deteriorating quality of nursing education in the Philippines,” Mayor says.
While she believes the test question leakage was an isolated case, Mayor attributes the low scores to the ongoing diploma mill problem. Some nursing schools in the Philippines have increased their enrollment beyond what their capacities and resources can handle, she explains. Because of their student overflow, these schools resort to hiring new graduates as teachers, effectively removing the clinical experience requirement that is essential to being a nursing instructor.
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