Success-Failure on the National Council Licensure Examination for Registered Nurses by Nurse Candidates From an Accelerated Baccalaureate Nursing Program ANDREWC.
MILLS, RN, MSN,* ANN M. BECKER, RN,MSN,t_
MARY E. SAMPEL, RN, MSN,$ AND VIVIAN C. POHLMAN, RN, MSN§
Nine years of data from first-time nurse candidates taking the National Council Licensure Examination for Registered Nurses (NCLEX-RN) were examined to identify predictors of successful performance and determine probabilities of success. Using logistic regression, four statistical models at strategic time periods during an accelerated baccalaureate nursing program were tested to see when intervention might be initiated to influence student performance on the NCLEX-RN. By the end of the first semester the model could predict failure for 94 per cent of those who failed, but it was less consequential in correctly predicting success of those who passed. Significant variables placing nurse candidates at risk included their first-semester grade point average, sex, and whether they were foreign educated. By the end of the second semester, with each full letter grade increase in cumulative grade point average, nurse candidates had a 46 times better chance of passing the NCLEX-RN; American-educated nurse candidates had a 4.5 times better chance of passing than their foreign-educated counterparts. At the end of the final semester, with each full letter grade increase on the final cumulative grade point average, nurse candidates had a 97 times greater likelihood of performing successfully on the NCLEX-RN. (Index words: Accelerated; Baccalaureate; Logistic; NCLEX-RN; Research) J Prof Nurs 8:357357,1992. Copyright 0 7992 by W.8. Saunders Company
T
RADITIONAL baccalaureate
nursing
programs
consist of a 4-year academic curriculum. Since 197 1 an alternative pathway has been available for
*Doctoral Candidate, Saint Louis University School of Public Health, St Louis, MO. TAssociate Professor, Saint Louis University School of Nursing, St Louis, MO. $Associate Professor, Saint Louis University School of Nursing, St Louis, MO. $Director, Baccalaureate Program, Saint Louis University School of Nursing, St Louis, MO. Address correspondence and reprint requests to Mr Mills: Saint Louis University School of Nursing, 3525 Caroline St, Sr Louis, MO 63 104- 1099. Copyright 0 1992 by W.B. Saunders Company 8755-7223/92/0806-0009$03.00/O
qualified
students
reate degree semester
who already
in another
curriculum
permits
elor of science in nursing students
with
possessed
discipline.
a proven
a baccalau-
A l-year,
completion
on an accelerated collegiate
three-
of the bach-
record.
track for For those
who apply to an accelerated nursing program, the choice to become a nurse is often a major change in career goals. Although prerequisite
a prior undergraduate
to admission,
applicants
degree is
may come with
master’s and doctoral degrees. The accelerated curriculum provides the opportunity to achieve the goal of entry into professional nursing more quickly. Within the context
of the current
nursing
shortage,
acceler-
ating the time and process by which students educated facilitates the short duration nursing
programs
may be
entry into the profession. Given and special nature of accelerated (Bell,
Simons,
& Norris,
1983),
nurse educators would be particularly interested in predicting the outcome of students, as nurse candidates, on the National for Registered characteristics
Council
Licensure
Nurses (NCLEX-RN). suggestive of successful
performance could provide guidance tors when counseling students.
Examination
Knowledge of or unsuccessful to nurse educa-
Therefore, the purposes of this study were twofold. The first was to identify predictors of success or, conversely, those predictors risk, on the NCLEX-RN
that would place them at for nurse candidates who
graduated from an accelerated baccalaureate program. The second purpose was to describe the probability of success for nurse candidates on their first attempt at the NCLEX-RN ables.
as a function
Review of Relevant
of the predicted
vari-
Literature
A long
history of interest in predicting performance on the examination for state licensure becomes evident
Journal of Professional Nursing, Vol 8, No 6 (November-December),
1992: pp 35 l-357
351
352
MILLS ET AL
when searching tigated from
programs.
associate
For the purposes
ate programs
of this study, education
to NCLEX-RN
suggestive
No
literature
was
baccalaure-
of NCLEX-RN
found
1990;
Glick,
Yang,
1986; Horns,
O’Sullivan,
Irvine
& Irvine,
1988; McKinney,
Small,
Payne & Duffey,
1986; Quick,
curric-
McClelland,
& Goodman,
Krupa,
Quick,
O’Dell,
was
averages at
the baccalaureate
(Dell & Valine,
in the
performance
grade point
&
Krupa,
1987) and standardized
1988;
& Whitley,
livan,
& Goodman,
McKinney, & Duffey,
1991;
test scores or
1990; Horns,
Irvine
1982 to
calaureate
at a private,
nursing
university.
program
Primary
data sources were student results submitted
by the state board of nursing. took the NCLEX-RN university
records
to the university
Nurse
candidates
who
in a state other than where the
is located were included
results were known.
bac-
midwestern
when performance
Data were collected
to assure the confidentiality
in a manner
of all individuals.
VARIABLES
prised preadmission criteria to a school of nursing. These consisted of high school ranking (Yang, Glick, (Dell & Valine,
from
from an accelerated
1991;
1985; Whitley & Chadwick, 1986). Another set of variables indicative of NCLEX-RN performance com-
their subscores
were first-time
1990. They were graduates
& Whitley,
& Coonrod,
& McClelland,
Cases for the study (N = 328) nurse candidates for the NCLEX-RN
and NCLEX-RN
performance.
course grades and/or
1987;
research
and NCLEX-
set of variables
selected time periods during ulum
baccalaureate
related accelerated
The most ubiquitous literature
and
was reviewed.
found that specifically
Methodology
have inves-
aspects of students
degree,
to both baccalaureate
performance
nursing
Researchers
and nonacademic
diploma,
salient RN
the literature.
academic
O’Sul-
& Irvine,
1987;
The following
variables
were examined
for mean-
ingful, statistical relationships. The dichotomous pendent variable was success or failure on NCLEX-RN;
failing
the NCLEX-RN
ence category. Independent didates’ age at the time whether
dethe
was the refer-
variables were nurse canof the examination; sex;
their prior education
had been in the United
States or in a foreign country
(the reference category);
their student transfer grade point average and graduate work, if applicable; and their student cumulative
Small, O’Dell, & Coonrod, 1988; Payne 1986; Quick, Krupa, & Whitley, 1985;
semester grade point averages at the end of each of the
Yang, Glick, & McClelland, 1987). Significant preadmission criteria also included collegiate course
three semesters. Male was the reference sex category. The interaction between age and grade point averages
work as prerequisite
to nursing
studies (Payne & Duf-
fey, 1986; Quick, Krupa, & Whitley, 1985; Whitley & Chadwick, 1986; Yang, Glick, & McClelland, 1987). Some researchers have indicated that standardized nursing
examinations
could be representative
future performance on the NCLEX-RN O’Sullivan, & Goodman, 1991; Irvine 1987;
Jenks,
McKinney,
Selekman, Small,
O’Dell,
Brass,
& Paquet,
& Coonrod,
of
(Horns, & Irvine, 1989;
1988).
Maximization of student performance is the ultimate goal.
was also tested for possible
significance.
The grading
system followed the usual four-point scale. For this study, if a student repeated a nursing course due to an unacceptable grade, the first grade recorded was calculated into the cumulative grade point average. Because of admission sign, during
requirements
the courses taken the
l-year
and curriculum
by the majority
accelerated
program
de-
of students are nursing
courses. A dummy variable was also created as an independent variable representing two time periods: 1982 to
. .
Maximization of student performance is the ultimate goal of most educator-student interactions. Guided by the b asic design of Payne and Duffey (1986), the present study sought to examine the historical problem of what strategic time periods might be most appropriate to initiate intervention when warranted for student development by anticipating students’ performance on the NCLEX-RN.
1987 and 1988 to 1990. This was to account for a possible statistical variation when the NCLEX-RN underwent a blueprint noticeable decrease in rates resulted from the in the pass or fail rates state or the university
change in 1988. Nationally, a the proportion of pass and fail change. However, no variation had been apparent in either the where the present study oc-
curred. STATISTICAL
METHODS
Descriptive and multivariate statistics were used to analyze the data. Because the study’s purpose included
353
SUCCESS-FAILURE ON NCLEX-RN
determining
the
NCLEX-RN
of the dependent gression nant
probability
and because variable
was deemed
analysis
(success-failure),
more applicable
or ordinary
Based on the method mation,
of success
least
of maximum
technique.
likelihood
regression
does not require
of normal
distribution
sumption dent BMDP
of multivariate
variables,
eg,
Statistical
wise logistic tested
eg, ordinary
normality
to determine
NCLEX-RN
as a function
predictors. The initial
model
ity, ie, the ability who actually
to predict
passed,
Using CA) step-
a series of four models
were
of passing
of statistically
fail-
and sensitiv-
success based on those
were calculated
using
an 89 per
cent cut point (based on the overall NCLEX-RN
suc-
cess rate at the university).
Results
the
significant
Only
those variables
cance was achieved
for which
are reported.
between
the
statistical
signifi-
Of the nurse candi-
dates (N = 328), 89.3 per cent passed the NCLEXRN (Table were foreign
1). Three per cent of the nurse candidates educated
at the university.
before their nursing
On the average,
who achieved success were slightly tested relationships
to predict
failed,
or the as-
of the indepen-
the probability
ie, the ability
ure based on those who actually
the clas-
analysis.
Software’s (Los Angeles,
regression,
esti-
The models’ specificity,
of the depen-
least squares,
discriminant
re-
than discrimi-
squares
logistic
variable,
the
nature
logistic
sical assumption dent
on
of the dichotomous
who failed.
Their
mean transfer
nurse younger
education candidates than those
grade point
average
dependent variable of success-failure and the independent variables of age, sex, whether American educated
and mean cumulative consistently higher.
or foreign educated, transfer grade point average, the dummy year variable, and the interaction between age
Distinctions between female and male nurse candidates are noted in Table 2. Proportionately, more
and transfer grade point average. This model examined the students’ profiles on admission to the uni-
females than males passed the NCLEX-RN.
versity.
The second model’s independent
cluded
age, sex, whether
eign educated, cumulative end of the first semester,
American
variables
educated
grade point the dummy
in-
or for-
average at the year variable,
and the interaction between age and cumulative grade point average. The third model advanced the second model’s variables by replacing the first semester’s with the second semester’s
cumulative
grade point
average
were also
On the
average, females were younger than males. The mean transfer grade point average for female nurse candidates was higher
than for males.
This was also con-
sistently true for their mean cumulative grade point averages. Nurse candidates’ prior education, ie, American educated and foreign educated, is also compared in Table 2. Of the 10 foreign-educated candidates who attempted the NCLEX-RN,
nurse 50 per
grade point average.
The final model further tested the relationship between success-failure on the NCLEX-RN and the previous variables except, again, it replaced the second semester’s cumulative grade point average with the students’ final cumulative grade point averages at the university. Cumulative grade point averages were chosen over individual course grades as the more statistically viable manner of examining course work. In the published literature, when individual course grades were used in statistical modeling, researchers seemed willing to make the assumption that courses were independent of each other, ie, that the curriculum did not build on acquired knowledge and skills. Although the problem of multicollinearity was occasionally addressed, the reported results remained theoretically troublesome. To examine if one particular model would suggest a best time period for remedial intervention in anticipation of students’ NCLEX-RN performance, classification matrices of the four models were constructed.
TABLE
1.
Descriptive Statistics Comparing NCLEX-RN Performance of Nurse Candidates from an Accelerated Baccalaureate Program Pass
Fail
Total
No. taking NCLEX-RN Sex
293
35
328
Female (83.2%) Male (16.8%) Foreign-educated
250 43
23 12
273 55
students (3%) Mean age in yr (SD) Mean transfer grade point average (SD) End of semester 1 mean cumulative grade point average (SD) End of semester 2 mean cumulative grade point average (SD) End of semester 3 mean cumulative grade point average (SD)
5 28.4
5 29.6 (9 0) 2.99
10 28.5
(6 1) 317 (0.34)
(0 38)
(6 4) 3.15 (0.35)
3 52 (0.40)
3 07 (0.28)
3.47 (0.42) 3.29 (0.40)
3.33
2.85
(0 36)
(0 31)
3 51 (0.29)
(0 27)
312
3 47 (0.31)
354 TABLE
MILLS ET AL
2.
Descriptive Statistics Comparing Female, Male, and American- and Foreign-Educated Nurse Candidates From an Accelerated Baccalaureate Program
Female
Male
Ametlcan
Foreign
NCLEX-RN Pass Fail
250 23
Sex Female Male Foreign-educated students Mean age in yr (SD)
43 12
55
5
266 52
3 31.1
318
10 33 7
(0.35)
(6.3) 2.97 (0.31)
28 4 (0.35) 3.15 (0.35)
3.49 (0.42)
3 35 (0.37)
3.49 (0.40)
3 06 (0.34)
3.31 (0.40)
3.14 (0.40)
3 29 (0.40)
2.92
3.49
3.35 (0.33)
(0 31)
27.9
(6.2) 3.18
more likely
(0 42) 3.06 (0.42)
est predictor
3.48
(0.40) 313 (0.35)
their foreign-educated counterparts. The mean cumulative grade point average showed a similar relationvariables
that achieved
who were American
had a
nine times better chance of passing the NCLEX-RN than nurse candidates whose prior education was in a foreign country. The transfer grade point average from the nurse candidates’ prior course work was also a significant predictor. For each full letter grade increase on transfer grade point average, ie, from 2.0 (C) to 3.0 (B), or 3.0 (B) to 4.0 (A), nurse candidates would have a nearly five times better chance of passing the NCLEX-RN. Between the two significant variables of this initial model, the 95 per cent confidence intervals suggested that being American educated provided the stronger predictability of performance; at minimum, those candidates would be nearly 2.5 times more likely to pass the NCLEX-RN than foreign-educated candidates. The initial model’s specificity was poor (54.3 per cent) and had a mediocre
more males.
were more than those who were
the wide 95 per cent confi-
of the three significant educated
times than
variables,
be-
proved again to be the strong-
of performance;
at minimum,
those can-
counterparts.
The
specificity of the second model suggested that 94.3 per cent of the nurse candidates who did not pass could have been correctly predicted at the end of the This was based on their poorer cumu-
lative grade point average and being male and foreigneducated. However, the sensitivity of the model was low (62.8 per cent). The overall classification
was mediocre
second correct
(66.2 per cent).
By the end of the second semester (third model), each full letter grade increase of the nurse candidates’ cumulative grade point average would give a 46.1 times greater chance in passing the NCLEX-RN. was no longer a significant variable in predicting
statistical
educated
2.5
to pass than
Given
succeed than their foreign-educated
TABLE 3.
significance (P d .05) in building each of the four models tested are shown in Table 3. For the initial model (on admission), the odds ratio indicated that
than
performance
grade
didates would be more than 4.5 times more likely to
first semester.
(0 30)
were more
nurse candidates
educated.
dence intervals
cent passed. The mean transfer grade point average for American-educated nurse candidates was higher than
nurse candidates
4.5 times
ing American
Mean transfer grade point average (SD) End of semester 1 mean cumulative grade point average (SD) End of semester 2 mean cumulative grade point average (SD) End of semester 3 mean cumulative grade point average (SD)
ship. The independent
Females
cu-
15 times better chance at
with each full letter
to have a successful
American-educated
288 30
the nurse candidates’
average at the end of the first
the NCLEX-RN
increase.
foreign 273
grade point
semester gave them a nearly
likely
correct
(67.4 per cent).
From the second model, mulative passing
Education
Sex
(68.9 per cent) as well as overall
sensitivity classification
Sex per-
Stepwise Logistic Regression Results: Odds Ratios and 95 Per Cent Confidence Intervals
Regression Models and Variables’
Ratios
95% Confidence Intervals
On admission
American educated+ Transfer GPA* Constant End of first semester Cumulative GPA+ Sex5 American educatedt Constant End of second semester Cumulative GPA+ American educatedt Constant End of final semester Cumulative GPA$ Constant
9.2 48 01
2 4-35.6 1 5-14
7
0.002-2.4
14.8 2.6 46 001
4 a-45.3 11-61 1 l-193 0 16E-4-0 02
46 1 47 0.2
12 l-176.0 1 G-21 9 O.l4E-50.004
97.0 0 2E-5
21 8-432 0 0 16E-7-0.26E-3
*Variables listed entered models at P s .05. TReference category is foreign educated *Odds ratio IS associated with full grade change SReference category is male.
SUCCESS-FAILURE
formance.
355
ON NCLEX-RN
Although
the 95 per cent confidence
val of the American-educated
variable
ligible
have been a mistake
importance,
it would
discard its significance
els. The third model’s sensitivity candidates grade
point
Although centage
implied
average
and being
to pass
The final model
(78.1
performers
right,
eg, the foreign-educated
candidates.
The
can be seen by the curve on the student
with
a 3.0 49
per cent chance
to pass, and the American-educated
nurse
with
candidate
the same transfer
with its
grade
point
average had about a 90 per cent chance.
probability
nurse
of passing
nurse candidates
(Fig 2), not only
candidates
have a lower
the NCLEX-RN,
but
male
also had a lower probability,
based on cumulative
grade point averages.
again
At the end
of the second semester (Fig 3), sex was not significant
per cent).
provided
final-semester
poorer
did foreign-educated
was less
overall per-
was achieved
nurse
By the end of the first semester
educated.
model
(68.6 per cent), the highest variables
candidates’
American
for American-educated
transfer grade point average had an approximately
mod-
that by the
predicted
of the third
of correct classification
significant
to
This was based on their cumulative
the specificity
consequential
neg-
79.2 per cent of the nurse
could have been correctly
the NCLEX-RN.
suggested
given results of previous
end of the second semester,
than
inter-
evidence
cumulative
in predicting
that the nurse grade point
av-
NCLEX-RN
for passing remained
success.
The probability
lower for nurse candidates
erage would give a 97 times better chance for passing
prior education
the NCLEX-RN for each full letter grade increase. Although the 95 per cent confidence interval was extremely wide, at minimum value each full letter grade
those who had been American educated. By the end of the final semester (Fig 4), the cumulative grade point
increase of the nurse candidates’ lative
grade
point
average
final-semester
would
give
cumu-
a nearly
22
average was the only significant
The logistic function nificant
variables
curves associated with the sig-
of the four models
are depicted
in
Figs 1 through 4. The curves allow the determination of an individual nurse candidate’s probability of success on the NCLEX-RN Based on their
transfer
at strategic grade
point
time averages
periods. on ad-
mission to the university (Fig l), the probability of passing the NCLEX-RN is lower for foreign-educated
D
Transfer Figure 1.
admission.
Probability
C
0
B
El*
An objective of this study was to determine a strategic time period when intervention by nurse educators might
be most
appropriate.
point averages were significant
Cumulative
predictors
grade
of NCLEX-
RN performance throughout the three-semester curriculum. The likelihood of their being strong predictors increases during the consecutive semesters. At the end of each semester would be the time for giving counsel.
Given
the intensity
and short
duration
of
accelerated nursing programs, remedial intervention becomes problematic. The quandary is not of delaying
D Cumulative
A
on
of NCLEX-
Discussion and Conclusions
Grade Point Average of success on the NCLEX-RN
predictor
than for
RN success. It should be noted that no interaction terms between variables were significant.
times greater likelihood for success. The final model’s sensitivity and specificity were more balanced and of meaningful consequence: 75.1 per cent of those who passed were correctly predicted to pass, and 7 1.4 per cent of those who failed were predicted to fail. The overall correct classification was 74.7 per cent.
had been in a foreign country
whose
Figure 2.
C+ B C Grade Point Average
l3+
A
Probability of success on the NCLEX-RN at the end of the first semester.
356
MILLS ET AL
100%
themselves
of formal
NCLEX-RN
review
and/or self-help media can give direction BOX
lower probabilities
of passing
tage to this approach nurse candidates
assistance.
as well
An advan-
is the time period
for self-study
available
to
after spring graduation
and before the NCLEX-RN
4on
to those with
the examination
as to those who wish additional 60%
programs
is offered
by the state
board of nursing. 2on
C
D
C+
the best time for predicting NCLEX-RN performance is at the end of the accelerated program. . .
I
F
B
A
B*
Cumulative Grade Point Average Figure 3 . Probability of success on the NCLEX-RN end of the second semester.
l
at the
If the end of the curriculum the forward progression riculum,
which
of students
would
defeat
through
the
the cur-
accelerated
ap-
proach, as much as the quantity and efficacy of intersemester and intrasemester remedial work that might be necessary in an already heavy program of studies. The results of the study show that the best time for predicting NCLEX-RN performance is at the end of the accelerated program. This is not the time period most satisfactory
to educators
when considering
how
the developing curriculum impacts on the academic progress of students in acquiring nursing knowledge and skills.
At the university
students
National
League for Nursing’s
Nursing
Achievement
may take the
level. With the probability for success given with the NLN test’s results, coupled with the probability associated with results of this study, nurse educators will be in a better position students
100%
at risk.
Advising
to give informed
counsel to
nurse candidates
to avail
-
should
be taken that these two populations from entering
accelerated
ought
nursing
to
pro-
grams. Whatever initial difficulty men may experience in the program, by the end of the curriculum sex a statistically
significant
variable
in de-
termining probabilities of NCLEX-RN performance. With students whose prior education was in a foreign country, two issues can be identified: (1) objective testing methods, ie, multiple choice questions and (2) language
skills.
Difficulty
is only part of the issue.
with the English Experience
would
language suggest
glish as a second-language are more inclined to experience difficulty in course work. Foreign-educated
60% -
-
20%
O%C F
of having lower probabilities of passing the NCLEXRN. The authors wish to emphasize that no inference
that even with university requirements of the Test of English as a Foreign Language, students having En-
60% -
40%
cant predictor. However, the results of the study suggest that men and foreign-educated people are at risk
is no longer
Test to assess their knowledge
and
program preclude (although this is
still an empirical question), should the focus of inquiry be at the front end, ie, preadmission? Previous collegiate course work was not a statistically signifi-
be excluded
(NLN) Comprehensive
and the intensity
lack of time during the accelerated effective and efficient intervention
D
C
C*
B
81
A
Cumulative Grade Point Average Probability of success on the NCLEX-RN Figure 4. end of the final semester.
at the
students, however, may be from English-speaking countries but are not comfortable with testing methods used in this country and at the university. Additional prerequisite work emphasizing objective testing methods may be considered in the best interest of this population. The lower probabilities of NCLEXRN performance for foreign-educated students extend through the second of the three-semester accelerated curriculum; however, by the end of the curriculum, being foreign educated is no longer a statistically significant difference in determining probabilities of NCLEX-RN performance.
SUCCESS-FAILURE
Although graphic demic
the variables
and academic variables
357
ON NCLEX-RN
in nature,
remain
were demo-
ditional
the role of nonaca-
positive
for this study a relevant
sphere of interest.
The results of Poorman
and Martin
importance
and self-perception
in antici-
on the NCLEX-RN.
For nurse
pating
of anxiety
performance
candidates
from
an
accelerated
which the pace and intensity
program
has been profound,
in ad-
on test-taking
cognitions,
could support
(199 1) suggest the
nursing
emphasis
and
and enhance
skills,
stress-reducing
self-generated behaviors
performance.
Acknowledgment The authors wish to thank Sharon M. Homan, PhD, biostatistician, School of Public Health at Saint Louis University, for her generosity in giving of her time and for her useful suggestions. _ _
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McKinney, J., Small, S., O’Dell, J., & Coonrod, B. A. (1988). Identification of predictors of success for the NCLEX and students at risk for NCLEX failure in a baccalaureate nursing program. Journal of Professional Nursing,
4, 55-59. Payne, M. A., & Duffey, M. A. (1986). An investigation of the predictability of NCLEX scores of BSN graduates using academic predictors. Journal of Profasional Nursing, 2, 326-332.
Poorman, S. G., & Martin, E. J. (1991). The role of nonacademic variables in passing the National Council Licensure Examination. Journal of Professional Nursing, 7, 2532. Quick, M. M., Krupa, K. C., & Whitley, T. W. (1985). Using admission data to predict success on the NCLEX-RN in a baccalaureate program. Journal of Profssional Nursing, 1, 364-368. Whitley, M. P., & Chadwick, P. L. (1986). Baccalaureate education and NCLEX: The causes of success. Journal of Nursing Education, -35, 94 10 1. Yang, J. C., Glick, 0. J., & McClelland, E. (1987). Academic correlates of baccalaureate graduate performance on NCLEX-RN. Journal of Professional Nursing, 3, 298306.
MILLS, RN, MSN,* ANN M. BECKER, RN,MSN,t_
MARY E. SAMPEL, RN, MSN,$ AND VIVIAN C. POHLMAN, RN, MSN§
Nine years of data from first-time nurse candidates taking the National Council Licensure Examination for Registered Nurses (NCLEX-RN) were examined to identify predictors of successful performance and determine probabilities of success. Using logistic regression, four statistical models at strategic time periods during an accelerated baccalaureate nursing program were tested to see when intervention might be initiated to influence student performance on the NCLEX-RN. By the end of the first semester the model could predict failure for 94 per cent of those who failed, but it was less consequential in correctly predicting success of those who passed. Significant variables placing nurse candidates at risk included their first-semester grade point average, sex, and whether they were foreign educated. By the end of the second semester, with each full letter grade increase in cumulative grade point average, nurse candidates had a 46 times better chance of passing the NCLEX-RN; American-educated nurse candidates had a 4.5 times better chance of passing than their foreign-educated counterparts. At the end of the final semester, with each full letter grade increase on the final cumulative grade point average, nurse candidates had a 97 times greater likelihood of performing successfully on the NCLEX-RN. (Index words: Accelerated; Baccalaureate; Logistic; NCLEX-RN; Research) J Prof Nurs 8:357357,1992. Copyright 0 7992 by W.8. Saunders Company
T
RADITIONAL baccalaureate
nursing
programs
consist of a 4-year academic curriculum. Since 197 1 an alternative pathway has been available for
*Doctoral Candidate, Saint Louis University School of Public Health, St Louis, MO. TAssociate Professor, Saint Louis University School of Nursing, St Louis, MO. $Associate Professor, Saint Louis University School of Nursing, St Louis, MO. $Director, Baccalaureate Program, Saint Louis University School of Nursing, St Louis, MO. Address correspondence and reprint requests to Mr Mills: Saint Louis University School of Nursing, 3525 Caroline St, Sr Louis, MO 63 104- 1099. Copyright 0 1992 by W.B. Saunders Company 8755-7223/92/0806-0009$03.00/O
qualified
students
reate degree semester
who already
in another
curriculum
permits
elor of science in nursing students
with
possessed
discipline.
a proven
a baccalau-
A l-year,
completion
on an accelerated collegiate
three-
of the bach-
record.
track for For those
who apply to an accelerated nursing program, the choice to become a nurse is often a major change in career goals. Although prerequisite
a prior undergraduate
to admission,
applicants
degree is
may come with
master’s and doctoral degrees. The accelerated curriculum provides the opportunity to achieve the goal of entry into professional nursing more quickly. Within the context
of the current
nursing
shortage,
acceler-
ating the time and process by which students educated facilitates the short duration nursing
programs
may be
entry into the profession. Given and special nature of accelerated (Bell,
Simons,
& Norris,
1983),
nurse educators would be particularly interested in predicting the outcome of students, as nurse candidates, on the National for Registered characteristics
Council
Licensure
Nurses (NCLEX-RN). suggestive of successful
performance could provide guidance tors when counseling students.
Examination
Knowledge of or unsuccessful to nurse educa-
Therefore, the purposes of this study were twofold. The first was to identify predictors of success or, conversely, those predictors risk, on the NCLEX-RN
that would place them at for nurse candidates who
graduated from an accelerated baccalaureate program. The second purpose was to describe the probability of success for nurse candidates on their first attempt at the NCLEX-RN ables.
as a function
Review of Relevant
of the predicted
vari-
Literature
A long
history of interest in predicting performance on the examination for state licensure becomes evident
Journal of Professional Nursing, Vol 8, No 6 (November-December),
1992: pp 35 l-357
351
352
MILLS ET AL
when searching tigated from
programs.
associate
For the purposes
ate programs
of this study, education
to NCLEX-RN
suggestive
No
literature
was
baccalaure-
of NCLEX-RN
found
1990;
Glick,
Yang,
1986; Horns,
O’Sullivan,
Irvine
& Irvine,
1988; McKinney,
Small,
Payne & Duffey,
1986; Quick,
curric-
McClelland,
& Goodman,
Krupa,
Quick,
O’Dell,
was
averages at
the baccalaureate
(Dell & Valine,
in the
performance
grade point
&
Krupa,
1987) and standardized
1988;
& Whitley,
livan,
& Goodman,
McKinney, & Duffey,
1991;
test scores or
1990; Horns,
Irvine
1982 to
calaureate
at a private,
nursing
university.
program
Primary
data sources were student results submitted
by the state board of nursing. took the NCLEX-RN university
records
to the university
Nurse
candidates
who
in a state other than where the
is located were included
results were known.
bac-
midwestern
when performance
Data were collected
to assure the confidentiality
in a manner
of all individuals.
VARIABLES
prised preadmission criteria to a school of nursing. These consisted of high school ranking (Yang, Glick, (Dell & Valine,
from
from an accelerated
1991;
1985; Whitley & Chadwick, 1986). Another set of variables indicative of NCLEX-RN performance com-
their subscores
were first-time
1990. They were graduates
& Whitley,
& Coonrod,
& McClelland,
Cases for the study (N = 328) nurse candidates for the NCLEX-RN
and NCLEX-RN
performance.
course grades and/or
1987;
research
and NCLEX-
set of variables
selected time periods during ulum
baccalaureate
related accelerated
The most ubiquitous literature
and
was reviewed.
found that specifically
Methodology
have inves-
aspects of students
degree,
to both baccalaureate
performance
nursing
Researchers
and nonacademic
diploma,
salient RN
the literature.
academic
O’Sul-
& Irvine,
1987;
The following
variables
were examined
for mean-
ingful, statistical relationships. The dichotomous pendent variable was success or failure on NCLEX-RN;
failing
the NCLEX-RN
ence category. Independent didates’ age at the time whether
dethe
was the refer-
variables were nurse canof the examination; sex;
their prior education
had been in the United
States or in a foreign country
(the reference category);
their student transfer grade point average and graduate work, if applicable; and their student cumulative
Small, O’Dell, & Coonrod, 1988; Payne 1986; Quick, Krupa, & Whitley, 1985;
semester grade point averages at the end of each of the
Yang, Glick, & McClelland, 1987). Significant preadmission criteria also included collegiate course
three semesters. Male was the reference sex category. The interaction between age and grade point averages
work as prerequisite
to nursing
studies (Payne & Duf-
fey, 1986; Quick, Krupa, & Whitley, 1985; Whitley & Chadwick, 1986; Yang, Glick, & McClelland, 1987). Some researchers have indicated that standardized nursing
examinations
could be representative
future performance on the NCLEX-RN O’Sullivan, & Goodman, 1991; Irvine 1987;
Jenks,
McKinney,
Selekman, Small,
O’Dell,
Brass,
& Paquet,
& Coonrod,
of
(Horns, & Irvine, 1989;
1988).
Maximization of student performance is the ultimate goal.
was also tested for possible
significance.
The grading
system followed the usual four-point scale. For this study, if a student repeated a nursing course due to an unacceptable grade, the first grade recorded was calculated into the cumulative grade point average. Because of admission sign, during
requirements
the courses taken the
l-year
and curriculum
by the majority
accelerated
program
de-
of students are nursing
courses. A dummy variable was also created as an independent variable representing two time periods: 1982 to
. .
Maximization of student performance is the ultimate goal of most educator-student interactions. Guided by the b asic design of Payne and Duffey (1986), the present study sought to examine the historical problem of what strategic time periods might be most appropriate to initiate intervention when warranted for student development by anticipating students’ performance on the NCLEX-RN.
1987 and 1988 to 1990. This was to account for a possible statistical variation when the NCLEX-RN underwent a blueprint noticeable decrease in rates resulted from the in the pass or fail rates state or the university
change in 1988. Nationally, a the proportion of pass and fail change. However, no variation had been apparent in either the where the present study oc-
curred. STATISTICAL
METHODS
Descriptive and multivariate statistics were used to analyze the data. Because the study’s purpose included
353
SUCCESS-FAILURE ON NCLEX-RN
determining
the
NCLEX-RN
of the dependent gression nant
probability
and because variable
was deemed
analysis
(success-failure),
more applicable
or ordinary
Based on the method mation,
of success
least
of maximum
technique.
likelihood
regression
does not require
of normal
distribution
sumption dent BMDP
of multivariate
variables,
eg,
Statistical
wise logistic tested
eg, ordinary
normality
to determine
NCLEX-RN
as a function
predictors. The initial
model
ity, ie, the ability who actually
to predict
passed,
Using CA) step-
a series of four models
were
of passing
of statistically
fail-
and sensitiv-
success based on those
were calculated
using
an 89 per
cent cut point (based on the overall NCLEX-RN
suc-
cess rate at the university).
Results
the
significant
Only
those variables
cance was achieved
for which
are reported.
between
the
statistical
signifi-
Of the nurse candi-
dates (N = 328), 89.3 per cent passed the NCLEXRN (Table were foreign
1). Three per cent of the nurse candidates educated
at the university.
before their nursing
On the average,
who achieved success were slightly tested relationships
to predict
failed,
or the as-
of the indepen-
the probability
ie, the ability
ure based on those who actually
the clas-
analysis.
Software’s (Los Angeles,
regression,
esti-
The models’ specificity,
of the depen-
least squares,
discriminant
re-
than discrimi-
squares
logistic
variable,
the
nature
logistic
sical assumption dent
on
of the dichotomous
who failed.
Their
mean transfer
nurse younger
education candidates than those
grade point
average
dependent variable of success-failure and the independent variables of age, sex, whether American educated
and mean cumulative consistently higher.
or foreign educated, transfer grade point average, the dummy year variable, and the interaction between age
Distinctions between female and male nurse candidates are noted in Table 2. Proportionately, more
and transfer grade point average. This model examined the students’ profiles on admission to the uni-
females than males passed the NCLEX-RN.
versity.
The second model’s independent
cluded
age, sex, whether
eign educated, cumulative end of the first semester,
American
variables
educated
grade point the dummy
in-
or for-
average at the year variable,
and the interaction between age and cumulative grade point average. The third model advanced the second model’s variables by replacing the first semester’s with the second semester’s
cumulative
grade point
average
were also
On the
average, females were younger than males. The mean transfer grade point average for female nurse candidates was higher
than for males.
This was also con-
sistently true for their mean cumulative grade point averages. Nurse candidates’ prior education, ie, American educated and foreign educated, is also compared in Table 2. Of the 10 foreign-educated candidates who attempted the NCLEX-RN,
nurse 50 per
grade point average.
The final model further tested the relationship between success-failure on the NCLEX-RN and the previous variables except, again, it replaced the second semester’s cumulative grade point average with the students’ final cumulative grade point averages at the university. Cumulative grade point averages were chosen over individual course grades as the more statistically viable manner of examining course work. In the published literature, when individual course grades were used in statistical modeling, researchers seemed willing to make the assumption that courses were independent of each other, ie, that the curriculum did not build on acquired knowledge and skills. Although the problem of multicollinearity was occasionally addressed, the reported results remained theoretically troublesome. To examine if one particular model would suggest a best time period for remedial intervention in anticipation of students’ NCLEX-RN performance, classification matrices of the four models were constructed.
TABLE
1.
Descriptive Statistics Comparing NCLEX-RN Performance of Nurse Candidates from an Accelerated Baccalaureate Program Pass
Fail
Total
No. taking NCLEX-RN Sex
293
35
328
Female (83.2%) Male (16.8%) Foreign-educated
250 43
23 12
273 55
students (3%) Mean age in yr (SD) Mean transfer grade point average (SD) End of semester 1 mean cumulative grade point average (SD) End of semester 2 mean cumulative grade point average (SD) End of semester 3 mean cumulative grade point average (SD)
5 28.4
5 29.6 (9 0) 2.99
10 28.5
(6 1) 317 (0.34)
(0 38)
(6 4) 3.15 (0.35)
3 52 (0.40)
3 07 (0.28)
3.47 (0.42) 3.29 (0.40)
3.33
2.85
(0 36)
(0 31)
3 51 (0.29)
(0 27)
312
3 47 (0.31)
354 TABLE
MILLS ET AL
2.
Descriptive Statistics Comparing Female, Male, and American- and Foreign-Educated Nurse Candidates From an Accelerated Baccalaureate Program
Female
Male
Ametlcan
Foreign
NCLEX-RN Pass Fail
250 23
Sex Female Male Foreign-educated students Mean age in yr (SD)
43 12
55
5
266 52
3 31.1
318
10 33 7
(0.35)
(6.3) 2.97 (0.31)
28 4 (0.35) 3.15 (0.35)
3.49 (0.42)
3 35 (0.37)
3.49 (0.40)
3 06 (0.34)
3.31 (0.40)
3.14 (0.40)
3 29 (0.40)
2.92
3.49
3.35 (0.33)
(0 31)
27.9
(6.2) 3.18
more likely
(0 42) 3.06 (0.42)
est predictor
3.48
(0.40) 313 (0.35)
their foreign-educated counterparts. The mean cumulative grade point average showed a similar relationvariables
that achieved
who were American
had a
nine times better chance of passing the NCLEX-RN than nurse candidates whose prior education was in a foreign country. The transfer grade point average from the nurse candidates’ prior course work was also a significant predictor. For each full letter grade increase on transfer grade point average, ie, from 2.0 (C) to 3.0 (B), or 3.0 (B) to 4.0 (A), nurse candidates would have a nearly five times better chance of passing the NCLEX-RN. Between the two significant variables of this initial model, the 95 per cent confidence intervals suggested that being American educated provided the stronger predictability of performance; at minimum, those candidates would be nearly 2.5 times more likely to pass the NCLEX-RN than foreign-educated candidates. The initial model’s specificity was poor (54.3 per cent) and had a mediocre
more males.
were more than those who were
the wide 95 per cent confi-
of the three significant educated
times than
variables,
be-
proved again to be the strong-
of performance;
at minimum,
those can-
counterparts.
The
specificity of the second model suggested that 94.3 per cent of the nurse candidates who did not pass could have been correctly predicted at the end of the This was based on their poorer cumu-
lative grade point average and being male and foreigneducated. However, the sensitivity of the model was low (62.8 per cent). The overall classification
was mediocre
second correct
(66.2 per cent).
By the end of the second semester (third model), each full letter grade increase of the nurse candidates’ cumulative grade point average would give a 46.1 times greater chance in passing the NCLEX-RN. was no longer a significant variable in predicting
statistical
educated
2.5
to pass than
Given
succeed than their foreign-educated
TABLE 3.
significance (P d .05) in building each of the four models tested are shown in Table 3. For the initial model (on admission), the odds ratio indicated that
than
performance
grade
didates would be more than 4.5 times more likely to
first semester.
(0 30)
were more
nurse candidates
educated.
dence intervals
cent passed. The mean transfer grade point average for American-educated nurse candidates was higher than
nurse candidates
4.5 times
ing American
Mean transfer grade point average (SD) End of semester 1 mean cumulative grade point average (SD) End of semester 2 mean cumulative grade point average (SD) End of semester 3 mean cumulative grade point average (SD)
ship. The independent
Females
cu-
15 times better chance at
with each full letter
to have a successful
American-educated
288 30
the nurse candidates’
average at the end of the first
the NCLEX-RN
increase.
foreign 273
grade point
semester gave them a nearly
likely
correct
(67.4 per cent).
From the second model, mulative passing
Education
Sex
(68.9 per cent) as well as overall
sensitivity classification
Sex per-
Stepwise Logistic Regression Results: Odds Ratios and 95 Per Cent Confidence Intervals
Regression Models and Variables’
Ratios
95% Confidence Intervals
On admission
American educated+ Transfer GPA* Constant End of first semester Cumulative GPA+ Sex5 American educatedt Constant End of second semester Cumulative GPA+ American educatedt Constant End of final semester Cumulative GPA$ Constant
9.2 48 01
2 4-35.6 1 5-14
7
0.002-2.4
14.8 2.6 46 001
4 a-45.3 11-61 1 l-193 0 16E-4-0 02
46 1 47 0.2
12 l-176.0 1 G-21 9 O.l4E-50.004
97.0 0 2E-5
21 8-432 0 0 16E-7-0.26E-3
*Variables listed entered models at P s .05. TReference category is foreign educated *Odds ratio IS associated with full grade change SReference category is male.
SUCCESS-FAILURE
formance.
355
ON NCLEX-RN
Although
the 95 per cent confidence
val of the American-educated
variable
ligible
have been a mistake
importance,
it would
discard its significance
els. The third model’s sensitivity candidates grade
point
Although centage
implied
average
and being
to pass
The final model
(78.1
performers
right,
eg, the foreign-educated
candidates.
The
can be seen by the curve on the student
with
a 3.0 49
per cent chance
to pass, and the American-educated
nurse
with
candidate
the same transfer
with its
grade
point
average had about a 90 per cent chance.
probability
nurse
of passing
nurse candidates
(Fig 2), not only
candidates
have a lower
the NCLEX-RN,
but
male
also had a lower probability,
based on cumulative
grade point averages.
again
At the end
of the second semester (Fig 3), sex was not significant
per cent).
provided
final-semester
poorer
did foreign-educated
was less
overall per-
was achieved
nurse
By the end of the first semester
educated.
model
(68.6 per cent), the highest variables
candidates’
American
for American-educated
transfer grade point average had an approximately
mod-
that by the
predicted
of the third
of correct classification
significant
to
This was based on their cumulative
the specificity
consequential
neg-
79.2 per cent of the nurse
could have been correctly
the NCLEX-RN.
suggested
given results of previous
end of the second semester,
than
inter-
evidence
cumulative
in predicting
that the nurse grade point
av-
NCLEX-RN
for passing remained
success.
The probability
lower for nurse candidates
erage would give a 97 times better chance for passing
prior education
the NCLEX-RN for each full letter grade increase. Although the 95 per cent confidence interval was extremely wide, at minimum value each full letter grade
those who had been American educated. By the end of the final semester (Fig 4), the cumulative grade point
increase of the nurse candidates’ lative
grade
point
average
final-semester
would
give
cumu-
a nearly
22
average was the only significant
The logistic function nificant
variables
curves associated with the sig-
of the four models
are depicted
in
Figs 1 through 4. The curves allow the determination of an individual nurse candidate’s probability of success on the NCLEX-RN Based on their
transfer
at strategic grade
point
time averages
periods. on ad-
mission to the university (Fig l), the probability of passing the NCLEX-RN is lower for foreign-educated
D
Transfer Figure 1.
admission.
Probability
C
0
B
El*
An objective of this study was to determine a strategic time period when intervention by nurse educators might
be most
appropriate.
point averages were significant
Cumulative
predictors
grade
of NCLEX-
RN performance throughout the three-semester curriculum. The likelihood of their being strong predictors increases during the consecutive semesters. At the end of each semester would be the time for giving counsel.
Given
the intensity
and short
duration
of
accelerated nursing programs, remedial intervention becomes problematic. The quandary is not of delaying
D Cumulative
A
on
of NCLEX-
Discussion and Conclusions
Grade Point Average of success on the NCLEX-RN
predictor
than for
RN success. It should be noted that no interaction terms between variables were significant.
times greater likelihood for success. The final model’s sensitivity and specificity were more balanced and of meaningful consequence: 75.1 per cent of those who passed were correctly predicted to pass, and 7 1.4 per cent of those who failed were predicted to fail. The overall correct classification was 74.7 per cent.
had been in a foreign country
whose
Figure 2.
C+ B C Grade Point Average
l3+
A
Probability of success on the NCLEX-RN at the end of the first semester.
356
MILLS ET AL
100%
themselves
of formal
NCLEX-RN
review
and/or self-help media can give direction BOX
lower probabilities
of passing
tage to this approach nurse candidates
assistance.
as well
An advan-
is the time period
for self-study
available
to
after spring graduation
and before the NCLEX-RN
4on
to those with
the examination
as to those who wish additional 60%
programs
is offered
by the state
board of nursing. 2on
C
D
C+
the best time for predicting NCLEX-RN performance is at the end of the accelerated program. . .
I
F
B
A
B*
Cumulative Grade Point Average Figure 3 . Probability of success on the NCLEX-RN end of the second semester.
l
at the
If the end of the curriculum the forward progression riculum,
which
of students
would
defeat
through
the
the cur-
accelerated
ap-
proach, as much as the quantity and efficacy of intersemester and intrasemester remedial work that might be necessary in an already heavy program of studies. The results of the study show that the best time for predicting NCLEX-RN performance is at the end of the accelerated program. This is not the time period most satisfactory
to educators
when considering
how
the developing curriculum impacts on the academic progress of students in acquiring nursing knowledge and skills.
At the university
students
National
League for Nursing’s
Nursing
Achievement
may take the
level. With the probability for success given with the NLN test’s results, coupled with the probability associated with results of this study, nurse educators will be in a better position students
100%
at risk.
Advising
to give informed
counsel to
nurse candidates
to avail
-
should
be taken that these two populations from entering
accelerated
ought
nursing
to
pro-
grams. Whatever initial difficulty men may experience in the program, by the end of the curriculum sex a statistically
significant
variable
in de-
termining probabilities of NCLEX-RN performance. With students whose prior education was in a foreign country, two issues can be identified: (1) objective testing methods, ie, multiple choice questions and (2) language
skills.
Difficulty
is only part of the issue.
with the English Experience
would
language suggest
glish as a second-language are more inclined to experience difficulty in course work. Foreign-educated
60% -
-
20%
O%C F
of having lower probabilities of passing the NCLEXRN. The authors wish to emphasize that no inference
that even with university requirements of the Test of English as a Foreign Language, students having En-
60% -
40%
cant predictor. However, the results of the study suggest that men and foreign-educated people are at risk
is no longer
Test to assess their knowledge
and
program preclude (although this is
still an empirical question), should the focus of inquiry be at the front end, ie, preadmission? Previous collegiate course work was not a statistically signifi-
be excluded
(NLN) Comprehensive
and the intensity
lack of time during the accelerated effective and efficient intervention
D
C
C*
B
81
A
Cumulative Grade Point Average Probability of success on the NCLEX-RN Figure 4. end of the final semester.
at the
students, however, may be from English-speaking countries but are not comfortable with testing methods used in this country and at the university. Additional prerequisite work emphasizing objective testing methods may be considered in the best interest of this population. The lower probabilities of NCLEXRN performance for foreign-educated students extend through the second of the three-semester accelerated curriculum; however, by the end of the curriculum, being foreign educated is no longer a statistically significant difference in determining probabilities of NCLEX-RN performance.
SUCCESS-FAILURE
Although graphic demic
the variables
and academic variables
357
ON NCLEX-RN
in nature,
remain
were demo-
ditional
the role of nonaca-
positive
for this study a relevant
sphere of interest.
The results of Poorman
and Martin
importance
and self-perception
in antici-
on the NCLEX-RN.
For nurse
pating
of anxiety
performance
candidates
from
an
accelerated
which the pace and intensity
program
has been profound,
in ad-
on test-taking
cognitions,
could support
(199 1) suggest the
nursing
emphasis
and
and enhance
skills,
stress-reducing
self-generated behaviors
performance.
Acknowledgment The authors wish to thank Sharon M. Homan, PhD, biostatistician, School of Public Health at Saint Louis University, for her generosity in giving of her time and for her useful suggestions. _ _
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