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.

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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.

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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.

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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.

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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.

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Mary Hanks, EdD, MSN, CNL, CNE
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