SYSTEMATIC REVIEWS AND META-ANALYSES

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Journal of Professional Nursing

journal homepage: www.elsevier.com/locate/jpnu

A closer look at first-time pass rates as the primary measure of program quality☆

Collette Loftin⁎, Helen Reyes, Vicki Hartin, Louise Rice Department of Nursing, West Texas A&M University, United States of America

A R T I C L E I N F O

Keywords: Nursing education First time pass rates NCLEX

A B S T R A C T

Background: The NCLEX pass rate is considered the premier indicator of program quality. Nursing programs utilize first-time pass rates (F-TPR) as a basis for making program decisions - especially when confronted with a falling rate. Purpose: This survey was conducted to identify the array of strategies implemented to improve or maintain F- TPRs. Additionally, we sought to ascertain whether responding programs had experienced a problematic F-TPR and their experience in the aftermath. Methods: This study utilized a descriptive survey of nursing programs. Data analysis included thematic analysis of an open-ended item and descriptive analysis of forced-choice items. Results: Nursing programs report F-TPRs heavily influence decisions and policy making especially regarding admission/progression policies, use of standardized exams, and most consider it one of the most influential factors in program decision-making. Conclusion: A recommendation is made for changing the requirement to the percentage of students passing within two attempts.

Introduction

The first-time NCLEX-RN pass rate is widely deemed to be the principal indicator of program quality and pre-licensure nursing pro- grams implement a variety of interventions to address poor NCLEX-RN outcomes. It is used by boards of nursing and pre-licensure nursing program accreditors as a measure of program effectiveness. State boards of nursing (BON) first-time pass rate (F-TPR) minimum re- quirements differ in method of calculation and range between 75 and 90% (Smith Glasgow et al., 2019). Others establish their minimum standard at a percentage of the national average rather than setting a specific benchmark. Additionally, nursing program accreditors have established minimum F-TPR expectations. While F-TPRs may not be the lone measure of quality for nursing education programs, and appeals for alternate measures have been made, F-TPRs remain the foremost measure (Giddens, 2009; Taylor et al., 2014; Pittman et al., 2019).

During 2010, the baccalaureate program at the authors' institution experienced its third year of below 80% NCLEX pass rate. The program was placed on conditional status by the Texas BON in keeping with the board's policies. This decrease in F-TPR followed our attempt to grow

the number of students graduating annually. Much effort had been put into our endeavor as we added a third cohort of qualified students during our summer semester. Adding an additional group meant we were admitting students who, while qualified, may not have been the most academically qualified of our applicants. Not long after this pro- gram expansion, we experienced our first downturn in pass rates.

What followed were multiple program modifications to address the F-TPR. These included implementation of stricter admission and pro- gression policies, design and implementation of a new curriculum, and introduction of standardized testing. The number of students admitted fell by 35%. Rarely was a policy decision made or program change discussed without someone asking, “What will this do to our pass rate?” The F-TPR, rather than increasing enrollment, became the predominant concern driving virtually all program decisions.

Review of literature

Many factors have been examined for their influence on F-TPRs - including student and program attributes. Both students and programs are negatively impacted by NCLEX-RN failures making them vital to

https://doi.org/10.1016/j.profnurs.2020.09.011 Received 22 June 2020; Received in revised form 24 September 2020; Accepted 29 September 2020

☆ We would like to acknowledge the generous funding for this project provided by the Delta Delta Chapter of Sigma Theta Tau International. These funds allowed us to provide gift cards to participants.

⁎ Corresponding author at: West Texas A&M University, OM 309, 2403 Russell Long Boulevard, Canyon, TX 79016, United States of America. E-mail address: [email protected] (C. Loftin).

Journal of Professional Nursing 36 (2020) 707–711

Available online 04 October 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.

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explore. Student success strategies and program policy changes are frequently introduced in response to decreasing F-TPRs; however, these strategies may take months or years to implement and even longer to generate results. While there is an abundance of published literature describing the implementation of strategies and practices, there are not recognized best practices for improvement (Smith Glasgow et al., 2019). Published improvement strategies consist of making changes to teaching and testing policies including: the use of standardized exams, revisions to admission and progression policies, faculty development plans, and curricula revisions. Because multiple changes are often im- plemented simultaneously, it is difficult to discern which individual intervention to credit with program achievements (Czekanski, Hoerst, & Kurz, 2018).

A commonly applied strategy in the effort to improve F-TPRs is utilization of standardized testing. Standardized exams are considered valuable by nursing programs as preparation for the NCLEX-RN exam. They are useful in a variety of manners - including their ability to pinpoint areas of student weakness, to identify students who may re- quire remediation prior to completing the nursing program, and to in- form faculty of gaps in course content and needed updates (Randolph, 2017). Timing of these exams varies widely. They are administered in an assortment of courses throughout the length of the program (Randolph, 2017), toward the end of the program as an exit exam (Smith Glasgow et al., 2019), or as a postgraduate exam to determine readiness for NCLEX (Monroe & Dunemn, 2020). Finally, programs can implement standardized exams in a “high-stakes” manner. For example, setting a benchmark score necessary for progression to the next level, as well as limiting the number of attempts a student will have to reach the required benchmark score.

Admission of academically strong students is presumed to be a high priority of all nursing programs and multiple studies have been con- ducted to identify which academic characteristics are most predictive of NCLEX success. SAT and ACT exam grades, pre-nursing grade point average (GPA), science GPA, and standardized pre-admission nursing test results are among the factors found to be useful in predicting NCLEX success (Czekanski, Hoerst, & Kurz, 2018; Mathew & Aktan, 2018). Student learning styles have also been recognized as predictors of NCLEX performance. Lockie et al. (2013) found that students with an accommodator learning style were less likely to be successful on the exam than those with an assimilator, converger, or diverger learning style.

Programs have reported tightening admission requirements in their attempts to meet F-TPR benchmarks (Czekanski, Hoerst, & Kurz, 2018; Pullen, 2017). They have also reported strengthening progression po- licies as a method of improving F-TPR performance. Examples of such changes include limiting the number of course failures a student may have (Pullen, 2017), increasing the use of objective testing to a higher percentage of the overall course score (Farley Serembus, 2016), and raising the passing grade requirement for each course (Czekanski, Hoerst, & Kurz, 2018).

Faculty development is an intervention found useful to programs attempting to improve F-TPRs (Quinn et al., 2018; Hooper & Ayars, 2017; Czekanski, Hoerst, & Kurz, 2018). In their study, Hooper and Ayars (2017) recounted that program directors required to write self- study reports in response to low F-TPRs found faculty development activities to be valuable in providing faculty with opportunities to im- prove their instructional strategies. Another beneficial faculty devel- opment activity is instruction aimed at preparing NCLEX style questions for faculty developed examinations (Quinn et al., 2018).

Other strategies programs have utilized to improve F-TPRs include curriculum revisions (Hooper and Ayars, 2017; Quinn et al., 2018; Koestler, 2015), addition of online case studies (Young et al., 2013), development of mentorship programs (Havrilla et al., 2018), and im- plementation of an overall continuous program improvement plan (Farley Serembus, 2016). Finally, a less commonly reported interven- tion found to be successful in improving F-TPRs is a post-graduate

coaching program included as a key component of an overall compre- hensive plan (Czekanski, Mingo, & Piper, 2018).

The nursing literature is replete with examples from individual programs showing that a multidimensional approach is common and allows programs to tailor strategies to fit the resources and needs of their individual program. While this literature provides a richly detailed view of the strategies employed for a single program there remains, however, a dearth of literature providing a bigger picture of the useful strategies. Therefore, it is essential to begin identifying the overall array of strategies that have been utilized by programs across the United States.

Purpose

Nursing programs put much effort into improving a declining F-TPR and maintaining a satisfactory F-TPR. Often, they are looking for im- mediate improvement in pass rates and may not be certain where to begin. While we can discern from the published literature what worked for an individual program, we still do not have a wide-ranging view of the approaches most utilized to address F-TPR issues. Therefore, the purpose of this study was to explore the array of strategies implemented by nursing programs across the United States to improve or maintain their F-TPR. Additionally, we sought to ascertain whether responding programs had experienced a problematic F-TPR and their experience in the aftermath.

Methods

Design

This study utilized a cross-sectional descriptive survey of registered nursing programs to determine what strategies they utilize to improve or maintain F-TPRs at levels required by individual states.

Sample and setting

The study sample included deans or directors from pre-licensure registered nursing programs (diploma, associate, and baccalaureate) across the United States. Email contact information was collected for 1447 nursing programs through state board of nursing websites and the Commission on Collegiate Nursing Education (CCNE) website. In most cases, this email contact information was provided for the nursing program director or dean, although some programs published contact information for an interim director.

Instrument

The data were collected utilizing a newly developed survey instru- ment. The survey instrument was developed for this project as no in- strument could be located related to the study topic and purpose. Following a literature review and with input from faculty members who had experienced a less than mandated annual F-TPR, investigators de- veloped a 24-item survey which included 21 forced-choice options. The answer format for the forced choice items was dichotomous: yes or no. Another item asked about the number of years the program had ex- perienced a down-turn in F-TPRs, if any. A second section of the survey was developed and included two open-ended item inviting respondents to expand on their experiences and observations regarding F-TPRs. Our intention was to provide the respondents with an opportunity to express their opinions in their own words. The survey was pilot tested with a group of experienced nursing faculty members for ease of completion and identification of necessary corrections. Additionally, feedback on items was solicited to determine face validity. Minor revisions were made to two of the forced-choice items for clarity. No demographic or identifying program information was collected.

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Procedure

Invitations were sent to the 1447 nursing programs identified as deans or directors Respondents were invited to participate through electronic Qualtrics surveys via email. The survey invitations were sent in groups by state. Completed surveys were collected without identi- fying participant or program information, allowing us to distinguish only the states from which we received responses. Twenty-eight survey invitations were returned as undeliverable, leaving 1419 considered to be delivered. A single reminder email was sent four weeks after the initial email was sent.

The survey was completed in 2018. In all, 269 responses were col- lected; however, 12 were partial responses and removed. Complete responses were received from 257 programs for a response rate of 18.25%. Responses were received from 39 states. To encourage parti- cipation, those who completed the survey and provided an email ad- dress at the end of the survey were entered into a drawing for $25 Amazon gift card. Twenty gift cards were distributed. Once the cards were delivered, all email addresses were deleted from the data. Prior to administration of the survey, the Institutional Review Board at West Texas A & M University approved the study and all participants implied consent by completing the survey.

Data analysis

Descriptive statistics were calculated for the forced-choice items. Answering the open-ended items was optional. Data analysis was completed on only one of the open-ended items in this manuscript as the second open-ended item received too few responses for analysis. This second item sought to identify what efforts had been utilized to increase F-TPRs above state requirements. Most of the responses re- ceived were brief and limited to a few words making a thematic ana- lysis problematic. With hindsight we recognize that this data had been collected in the forced-choice options.

A thematic analysis of the first open-ended item was achieved by careful reading of the received responses, development of categories, and formation of themes by one of the investigators experienced in qualitative data analysis. The remaining investigators evaluated the data and consensus was reached on each of the themes.

Findings

Of the programs responding, 58.4% (n = 150) reported having experienced an annual F-TPR of less than the state mandated minimum at least once in the past 10 years. Table 1 presents responses from these programs. The most common program responses include making changes to admission criteria (75%), adjusting or revising curriculum

(78%), and implementing stricter progression policies (76%). The least frequently reported responses included suspending program admissions (13%) followed by decreasing the number of students admitted (28%).

After a decline in their F-TPR was publicized, student applications dropped for 27% of the programs and 24% reported a reduction in faculty applications. Sixty percent of the respondents reported that the drop in F-TPR was a source of embarrassment for the program's faculty. Finally, 64% of the programs reported that their faculty were required to participate in faculty development as a result of the decrease in F- TPRs.

For the programs reporting a problematic F-TPR, 45% shared that they had experienced a single year that was less than the state required minimum pass rate. Of those experiencing more than a single year below the minimum requirement, the percentages were as follows: (1) 37% reported two years in a row, (2) 11% reported three years in a row, (3) 6% reported four or more years in a row.

Table 2 presents findings from all (N = 257) responding programs regardless of whether they had experienced a problematic F-TPR or not. When asked whether their program regularly turned away qualified applicants, 65% reported that they did. Regarding faculty and clinical site shortages, the majority reported experiencing both - with 66% undergoing a faculty shortage and 59% facing a clinical site shortage. Concerning teaching and learning policies, 84% of responding pro- grams reported making changes to their policies based on F-TPRs. Ninety-seven percent of responding programs set a limit on the number of courses a student can fail and remain eligible to progress in the program. When asked whether they reach out to students who do not pass NCLEX on their first attempt, 61% of programs reported that they do.

The survey asked programs whether they utilized standardized exams with 94% (n = 241) responding that they did. Of these 241 programs, 82% (n = 197) reported that this practice was related to efforts to increase F-TPRs. Finally, programs were asked whether they consider the F-TPR to be the most influential factor when making program related decisions. Fifty-nine percent (n = 151) reported that it was. Those who responded that the F-TPR was not the most influential (n = 103) were then asked whether the F-TPR was one of the top three most influential factors in program related decision-making. Eighty- nine percent (n = 92) reported that it was one of the top three most influential factors. Ninety-five percent of respondents (n = 243) report the F-TPR is either the most influential or one of the three most influ- ential factors they consider when making program related decisions.

Of the 257 survey respondents, 129 responded to the first open- ended item. This optional open-ended item allowed educators to share their experiences, ideas, and concerns about F-TPRs and added com- pelling details to the information gathered through the dichotomous items. When asked what they would like us to know about their ex- periences but had not previously had an opportunity to share, we re- ceived responses that fell into five themes. The themes that emerged were: (1) F-TPR is necessary and a good consumer protection metric; (2) F-TPR must be linked with completion rate; (3) other metrics should be used; (4) consider other important factors like diversity and student demographics; and (5) much is out of the program's control regarding pass rates. There were additional faculty comments about pass rates that, while not fitting into earlier themes, are important and reveal further points of view.

Theme 1 – F-TPR is necessary and good for consumer protection

A small number of programs described having had no problems with their F-TPR and shared that “it is important to have a baseline minimum pass rate” (P16) and “feel that it is a good consumer pro- tection metric” (P51). Another comment was, “This is not a new re- quirement. We are held to this standard and should be” (P166). One respondent shared that while the F-TPR was “annoying”, it was also “necessary” and allowing that “we rise to the bar that is set” (P252).

Table 1 Responses from programs who have experienced a lower than mandated F-TPR (n = 150).

Agreed/yes n (%)

Did your program temporarily suspend admissions until pass rates improved?

19 (12.66%)

Did your program decrease number of students admitted? 42 (28%) Did your program make changes to admission requirements? 112 (75%) Did your program make changes to the curriculum? 117 (78%) Did your program implement stricter progression policies? 114 (76%) Was your pass rate publicized to local media? 72 (48%) In your opinion, were faculty members embarrassed by

publication of programs pass rate? 90 (60%)

Did your program experience a reduction in student applications? 41 (27%) Did your program experience a reduction in faculty applicants? 36 (24%) Were your faculty required to participate in faculty development

as a result of decreased pass rate? 95 (64%)

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Theme 2 – link F-TPRs with completion rates

An inverse relationship was perceived as programs recounted challenges with preserving F-TPRs and at the same time maintaining completion rates, reporting that when one went up the other dropped. In response to falling F-TPRs, one respondent wrote, “when we made our progression policy stricter our pass rates went up, but attrition became our new problem” (P80). Another shared, “if the students can make it through our program, their chance of passing is very high” (P26). An additional comment included, “We have made many changes and our pass rate has been 100% for three years straight, but the cost of that high NCLEX pass rate has been at the cost of higher attrition” (P92).

Theme 3 – preference for another measurement – within one year or two attempts

Open-ended responses suggest that numerous programs prefer an alternative method of measurement such as pass rate within one year, pass rate with two attempts, or inclusion of completion rate. One re- spondent commented, “Even though we have a 100% first time pass rate, I feel that it would be more accurate to look at overall pass rate within a defined period of time” (P196). Another suggested that more programs would be motivated to “continue working with graduates in a meaningful way after a first attempt failure if the pass rates were cal- culated as within one year or by second attempt” (P28). Finally, one more comment on F-TPRs was, “it is too heavily weighted. Should be a range with completion rates considered” (P261).

Theme 4 – other factors to consider – diversity and other student demographics

Diversity and student demographics are a concern of some pro- grams. One program shared that concern over F-TPR “influenced us to be more selective in admissions and progression, resulting in less di- versity in our graduates” (P110). Another shared, “There is little con- sideration taken into account for student demographics and variance in life experience. In areas plagued by difficult socioeconomic conditions, basic skills in reading, math and test taking can be missing. First-time pass rates have a place – but are a one-size-fits-all metric” (P27).

Theme 5 – much is out of the programs' control

Interestingly, programs reported that there were factors they felt were out of their control regarding pass rates. Respondents expressed a desire for less “pressure” on programs “with so many factors we can't control” (P67). These factors include the time between graduation and testing, working and family issues, and student stress and anxiety that could affect testing performance. Comments included, “Our belief is that if a student has not taken the NCLEX within the first year of

graduation it should not be held against a program” (P156) and “If students does not take the exam within 6 months or a year out…they should be mandated to take a review course” (P171). An additional comment included “Sometimes students just get nervous and don't pass, maybe they didn't sleep well the night before or might just had so much stress/anxiety that they could not think straight” (P149). Others re- flected that, “Some of last years students admitted they didn't study a lot before taking it because they knew they could take it again!!!!” (P243) and “Current students have expressed that they don't mind failing the first time – that way they can see what the test is really like” (P214). It was a commonly repeated sentiment that students often make their first attempt without much preparation, “just to see how they would do”(P74) or “to see what it was like” (P101) knowing they would be allowed to repeat it.

Additional faculty remarks on pass rates

There were many comments made about the pass rate requirement that did not necessarily fit into the earlier themes but were nevertheless important to share. These include:

a) “The scrutiny by States Boards regarding NCLEX Pass Rates on the first attempt is a primary reason for the nursing shortage. Programs are hesitant to admit students who may be good practitioners, but who require academic remediation” (P139).

b) “The 80% requirement for first time test takers influences every decision we make. Faculty believe that this eliminates many stu- dents, who would be great RNs, even if they required multiple times to pass the NCLEX” (P187).

c) “Although our below 80% pass rate was not publicized it was well known within the community which resulted in embarrassment” (P200).

d) “When your first-time NCLEX pass rate is below benchmark, your colleagues and peers treat you like the plague. It is extremely hu- miliating sitting in front of the board of nursing. You walk feeling like you are branded useless” (P215).

e) “It is with us all the time, running in the background, what ever we do or think of doing” (P238).

Discussion of findings

Virtually every nursing program in the U.S. must meet F-TPR re- quirements or suffer adverse consequences. While this metric has value in assessing a nursing program, it has additional consequences that ought to be considered. The tension between maintaining an acceptable pass rate and the crucial goal of educating future nurses manifests when a program falls below the minimum required pass rate.

The findings of this study reveal that nursing programs experiencing a downturn in pass rates often institute modifications to admission criteria and progression policies. This aligns with previous studies

Table 2 Responses from all programs about F-TPR issues.

Agreed/yes n (%)

Does your program make admission policy decisions based on F-TPRs? 104 (40.5%) Does your program regularly turn away qualified applicants? 167 (65%) Does your program make changes in teaching and learning policies based on F-TPRs? 215 (84%) At any time in the past 5 years, did you experience a faculty shortage? 170 (66%) At any time in the past 5 years, did you experience a clinical site shortage? 150 (58.5%) Do you have a limit on the number of courses a student can fail and remain eligible to progress? 248 (96.5%) Does your program utilize standardized exams? 241 (94%) If your program utilizes standardized exams, is this related to efforts to increase F-TPRs? 197 (82%) Does your program reach out to students who were not successful on the first NCLEX attempt? 156 (61%) Would you consider the F-TPR to be the most influential factor in program related decision making? 151 (59%) Of those who responded that the F-TPR was not the most influential, is it one of the top three factors? 92 (89%)

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finding that nursing programs report tightening admission criteria as one of the earliest strategies implemented (Czekanski, Hoerst, & Kurz, 2018; Pullen, 2017). Clearly, raising admission criteria can decrease the number of students eligible for admission (Farley Serembus, 2016). It may also eliminate mature learners who have developed strong po- tential despite a poor academic history from earlier attempts at higher education. Virtually all nursing programs responding to this survey also limit the number of courses a student can fail and remain eligible to progress. Consequently, it is vital to identify students at risk for failure and initiate remedial efforts as early as possible (Hooper & Ayars, 2017). Farley Serembus (2016) relates that it can be difficult to identify students at risk for NCLEX failure and all students will benefit from best practices.

The financial resources of a nursing program influence the pro- gram's response to an undesirable pass rate. Modifications to admission criteria and progression policies are not necessarily costly and they can be effective. It is important to note that changes to these policies, while designed to improve pass rates, may ultimately have the unintended consequence of limiting the number of students graduating from the program. On the other hand, hiring additional faculty, expanding fa- culty development activities, and enhancing teaching, learning, and remediation opportunities for students (such as simulation and tutoring labs) can require substantial financial resources. The range of options available to a program is determined, to a large extent, by the funds available to the program.

The findings of this study are consistent with the Smith Glasgow et al. (2019) report that deficits in pass rates may lead to reputational damage. Although not frequently mentioned in the literature, anecdotes recounted in this study described experiences of feeling “humiliated” and “useless.” This damage to faculty and program can be difficult to overcome.

Nearly all programs responding to this survey reported that the F- TPR is either the most influential or one of the top three most influential factors in program related decision making. It is surprising that this single statistic plays such a dominant role in program decision making. And it is troubling as well, because it can be an obstacle to young men and women desiring to become nurses. In their three-year study de- scribing NCLEX testing patterns of students in Oregon, Noone et al. (2018) found that 96.1% of testers passed by their second attempt. Noone et al. suggested that programs assess second time pass rates before making program decisions and implementing major program policy changes.

Limitations

This study represents a preliminary effort in exploring program re- sponses to F-TPRs and has several limitations that should be considered when interpreting the findings. First, the responses were the percep- tions of a single person from each program. While this person is likely to be the program director or dean, the response may not provide a comprehensive representation for that program. In future studies, it is recommended that additional faculty members from each program complete the survey. A second limitation is the response rate. A more robust response may have yielded different results. Finally, the instru- ment utilized for this study was newly developed and requires further testing to assess reliability and validity. Findings indicate that clar- ification of the second open-ended item would have been beneficial.

Conclusions & recommendations

Given the findings of this nationwide study, strong consideration should be given to another quality indicator and a credible choice would be the percentage of students passing within two attempts. This allows programs to reach out to those graduates who failed on their first attempt - providing them much needed assistance and support in pas- sing the exam on their second attempt. This is a win-win for both

program and student. Other valid indicators of program quality that merit consideration by accreditors and state boards of nursing are graduation rates, program growth in overall numbers and diversity, and increased employment in an area otherwise experiencing a nursing shortage.

Educators are aware that the days leading up to the graduate's NCLEX exam may be stressful. Therefore, careful counseling for stu- dents about the importance of NCLEX exam preparation is essential. Reminding students about reaching out for study help as needed, creating a restful environment prior to sitting for the exam, and maintaining healthy behaviors in the days and weeks leading up to the exam may prove to be helpful in passing on the first attempt.

Although we expected that others shared in our experience with F- TPRs, we were surprised at how closely our experiences were mirrored across those of other programs. Therefore, a final recommendation we offer is to begin a nation-wide discussion on the debatable value of utilizing F-TPRs as the foremost indicator of pre-licensure nursing program quality. Nursing educators and leaders must begin to speak out on the F-TPR driven actions that limit admission, impede progression, decrease graduation, and likely contribute to the ongoing nationwide nursing shortage.

The findings from this study lay the groundwork for additional studies regarding F-TPRs. While this research provides initial guidance to program policymakers on the potential strategies to be considered, there is no literature reporting which strategies are most effective, nor the resources required for implementation. Further research aimed at uncovering these strategies would be beneficial. Additionally, we re- commend a study to explore the inverse relationship between tigh- tening of progression policies and student attrition.

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