Online remediation utilization and program consequences effect on outcomes of Elsevier HESI(TM) Exit Exam (E2) scores
v Table of Contents Acknowledgments iv List of Tables viii List of Figures x CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 3 Theoretical Framework 5 Statement of the Problem 6 Purpose of the Study 7 Rationale 8 Research Questions and Hypotheses 9 Significance of the Study 9 Definition of Terms 10 Assumptions and Limitations 11 Nature of the Study 12 Organization of the Remainder of the Study 13 CHAPTER 2. LITERATURE REVIEW 14 Student-Centered Theories 14 Predictors of NCLEX–RN Success 18 Progression and Predictor Exams 21 Remediation Methods 24 Remediation Methods Based on Learning Styles 28
vi CHAPTER 3. METHODOLOGY 30 Introduction 30 Research Design 31 Setting 32 Population and Sample 32 Protection of Human Subjects 33 Instrument 34 Restatement of Research Questions 34 Data Collection 35 Data Analysis 35 CHAPTER 4. DATA COLLECTION AND ANALYSIS 39 Introduction 39 Data Preparation 40 Description of Population 40 Sample Descriptive Statistics 41 Data Analysis & Results 43 Summary 54 CHAPTER 5. RESULTS, CONCLUSIONS, RECOMMENDATIONS 56 Introduction 56 Discussion and Findings 57 Strengths and Limitations 62 Implications for Nursing Education 64 Recommendations for Further Research 64
vii Conclusion 64 REFERENCES 66
viii List of Tables Table 1. Demographics of V8S Nursing Programs That Reported E 2 Scores 40 Table 2. Mean E 2 Scores for Nursing Programs Participating in V8S 41 Table 3. Schools That Utilized Elsevier HESI Online Remediation 41 Table 4. Students Who Utilized Elsevier HESI Online Remediation 42 Table 5. Schools in the Population That Had Program Consequences 42 Table 6. Students in the Schools in the Population That Had Program Consequences 42 Table 7. Descriptive Statistics Measuring Schools That Utilize Elsevi er HESI Online Remediation 45 Table 8. Paired Samples t Test for Students From Schools That Utilize Elsevier HESI Online Remediation 45 Table 9. Descriptive Statistics Measuring Schools That Do Not Utilize Elsevier HESI Online Remediation 46 Table 10. Paired Samples t Test for Students From Schools That Do Not Utilize Elsevier HESI Online Remediation 47 Table 11. Repeated Measures ANOVA Comparing HESI Exam Performance Over Time for Schools Utilizing and Schools Not Utilizing Elsevier HESI Online Remediation 48 Table 12. Descriptive Statistics Measuring Students’ E 2 From Schools That Have Program Consequences for Remediation to Those That Do Not Have Program Consequences for Remediation 50 Table 13. Independent Samples t Test for Equality of Means When Comparing Schools With Consequences to Schools Without Consequences 51 Table 14. Levene’s Results Testing the Statistical Assumption of Homogeneity of Variance 51 Table 15. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Have Capstone Course Failure as a Consequence for Remediation to Those That Do Not 52
ix Table 16. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Delay/Deny Graduation as a Consequence for Remediation to Those That Do Not 52 Table 17. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Delay/Deny NCLEX Candidacy as a Consequence for Remediation to Those That Do Not 52 Table 18. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Have Course Failure as a Consequence for Remediation to Those That Do Not 53 Table 19. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Have Students Retake the Exam as a Consequence for Remediation to Those That Do Not 53 Table 20. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Have Other Consequence for Remediation to Those That Do Not 53 Table 21. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Have Consequence for Remediation 61 Table 22. Descriptive Statistics Measuring Students’ E 2 Scores and the Mean Number of Remediation Methods Used 63 Table 23. Descriptive Statistics Measuring Students’ E 2 Scores From Schools That Require Remediation and Those That Do Not 63
x List of Figures Figure 1. E 2 scores by test and group 49
CHAPTER 1. INTRODUCTION
The economic crisis of 2009 has been the topic of much discussion in the United States. President Obama has addressed the crisis by emphasizing the need to e ducate Americans and bolster graduation rates for 2-year community colleges. Th e American Graduation Initiative (Obama, 2009) outlines a plan for making America the most educated country in the world by 2020. This initiative is important because 2-year Associate Degree Nursing (ADN) programs educate nearly 40% to 58% of our nation’s nurses (National League for Nursing, 2009; Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001). Bachelor of Science in Nursing (BSN), ADN and diploma nursing programs have realized increased admissions; however, many students never gra duate due to high attrition rates. The issue of attrition is especially important to nursing programs because the average rate can vary between 20% and 70% in all nursing programs (Higgins, 2005; Pennsylvania Higher Education Assistance Agency [PHEAA], 2002). Remediation programs are one way to decrease attrition rates. To satisfy the workforc e demand and decrease attrition rates, nursing programs must work on remediation efforts geared towards assisting students to successfully complete the program and subsequent pa ssing of national board exams.
2 To this end, the American Graduation Initiative is significant because this initiative can help alleviate the country’s national nursing shortage. According t o the Health Resources and Services Administration, the shortage of registered nur ses will be 36% nationally by the year 2020 (Biviano, Tise, Fritz, & Spencer, 2004). The reasons for the nursing shortage are multifaceted and include the lack of enrollment in nursing schools, a nursing faculty shortage, an increase in the rate of retired nurses nationwide, and an aging population (American Association of Colleges of Nursing, 2010). Additional factors to consider include attrition rates for all nurs ing programs, which can vary between 20% and 70% (Higgins, 2005; PHEAA, 2002), and the first-time pass rate of 89.9% on National Council Licensure Examination (NC LEX– RN ® ) for all nursing school graduates (National League for Nursing, 2009). To decrease the nursing shortage, nursing schools would benefit from a comprehensive approach that focuses on decreasing the attrition rate and increa sing the success of first-time pass rates on the NCLEX–RN. One approach nursing schools can use to contribute to resolving the shortage would be to improve the remediation process for learners who are in the nursing program. By doing so, nursing schools would inc rease the number of students who are retained in the nursing program, who then graduate, and successfully pass NCLEX–RN. The focus of this quantitative study is twofold: first, to determine if utilizati on of the Elsevier HESI™ online remediation (formerly Evolve Reach Student Online Exa m Remediation) created for Elsevier HESI Exit Exam (E 2 )
is an effective means of improving scores on E 2 , and second, to determine if other variables such as course consequences effect the performance on the E 2 . Examples of program consequences
3 examined included attaching a grade to the E 2
or not allowing students to pass the course until a specific benchmark was met. The individual variables were examined to dete rmine if there is an increase in E 2
scores for those schools that employ program consequences.
Introduction to the Problem Currently, there are three different types of nursing programs for entry i nto the field of registered nursing (RN). All three types qualify the graduate to t ake the NCLEX– RN. The three types of programs are diploma or hospital-based nursing program s, ADN, and BSN. All three levels must meet minimal competency requirements for entr y into the field of nursing. In the last decade, the first-time pass rates have dropped f or all three levels due to the complexity of the exam itself. The decline in first-time pa ss rates has been addressed in all three nursing programs by using progression and predictor exa ms geared towards increasing first-time pass rates on NCLEX–RN. To date, there have been eight studies establishing the validity of the E 2
as an indicator of NCLEX–RN success (Lewis, 2008; Morrison, Adamson, Nibert, & Hsia, 2004; Newman, Britt, & Lauchner, 1999; Nibert, Young, & Adamson, 2002; Nibert, Young, & Britt, 2003; Yoho, Young, Adamson, & Britt, 2007; Young & Langford, 2011). To this end, many nursing schools have instituted policies for reaching designated benchmarks for the E 2 . The nursing student is challenged with meeting the designated benchmark, if the benchmark is not met, the student may be required to complete a remediation process. There are various techniques currently used to assist the s tudent in achieving remediation including group remediation, tutoring sessions, audiovisual remediation, individual studying, or customized remediation (Arathuzik & Aber, 1998;
4 Frierson, Malone, & Shelton, 1993; Murray, Merriman, & Adamson, 2008; Nibert et al., 2003; Sifford & McDaniel, 2007). One such remediation method that is currently being utilized to increase E² exam scores is the Elsevier HESI online remediat ion content. The Elsevier HESI online component consists of practice exams, customized study pla ns related to performance of the practice exams, and online resources applicable to current textbooks and web-related resources. The Elsevier HESI online remediation is a resource that can be accessed online . Learners who have completed the E 2
are given results of their first exam and an individualized study plan. The study plan includes specific detail on areas needin g review and includes a plan for remediation based on test scores. The individualized study plan for students is based on the student’s performance on the E 2 . The learner is provided a personalized study plan related to content missed on the exam. The study plan include s online resources from published nursing textbooks, video tutorials, web quests, and practice questions based on identified areas needing improvement. The learner com pletes the remediation and is then administered another version of the E 2 . The American Graduation Initiative also encourages educators to create onl ine skills laboratories that are interactive and customizable for individual student s’ learning needs. “Interactive software can tailor instruction to individual students like hum an tutors do, while simulations and multimedia software offer experiential learning” ( Obama, 2009, p. 1). Elsevier HESI Testing and Remediation by Elsevier Publishing Inc., is an integrated system for online testing and remediation that provides nursing student s with a custom, personalized remediation plan of study based on results of the E² exit exa m. The purpose of this research study is to determine the effectiveness of the Elsevi er HESI
5 online remediation at increasing E 2
scores and to examine the role of program consequences at increasing E 2
Theoretical Framework The theoretical framework of the study couples the andragogical principles of Knowles (1975) and the neomillennial learning style (NLS) theory (Dede, 2005). B oth were selected based on the fundamental nature of the Elsevier HESI online rem ediation resource, which incorporates principles of the adult learning coupled with an online learning experience that is customized to the learning preferences of today’s 21st-century learner. The assumptions of the self-directed learners are that learners “seek to ta ke the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources f or learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes” (Knowles, 1975, p. 14). Self-directed learners are active participants in t he process of learning. The learner creates goals, determines learning nee ds, and evaluates their own performance (Knowles, 1980). For this reason, learners benefit from receivi ng immediate feedback for performance on assessments. This feedback, when c ustomized, assists the learner in evaluating their learning progress and reaching ma ximal potential for passing NCLEX–RN. In the learner-centered environment, the facilitated learning takes place w hen adults see value in what they are learning and are able to apply classroom educ ation to real life experiences (Knowles, 1980). The post secondary educator can incorporat e
6 problem-solving techniques by using teaching strategies that promote active t hought, customizing learning experiences to fit individual learning needs and prefere nces, and providing opportunities for remediation. The Elsevier HESI online remediation resourc e can facilitate learning in the student-centered environment by assessing the individual needs and creating a customized study plan that is based on the individual’s performanc e on the E 2
Statement of the Problem There is a gap in the research literature regarding how and to what extent progra m the Elsevier HESI online remediation effect scores on subsequent E 2
scores. There is also a gap in the research regarding the use of program consequences and their effect on E 2
scores. Research supports the use of the Elsevier HESI predictor exams to predict students at risk for failing NCLEX-RN (Nibert et al., 2002; Nibert et al., 2003; Y oho et al., 2007), it would be useful to know if program consequences and/or the online remediation resources are in fact an effective means for increasing s ubsequent E 2
scores. Nursing educators and students currently remediate in a number of ways including group remediation, tutoring sessions, audiovisual remediation, individual studying, or customized remediation (Arathuzik & Aber, 1998; Frierson et al., 1993; Murray et al., 2008; Nibert et al., 2003; Sifford & McDaniel, 2007); however, little is known about the effectiveness of the Elsevier HESI online remediation content. Nursi ng programs, educators, and students may benefit from the results particularly if the online remediation efforts are effective in increasing E 2
scores, which in turn contribute to positive outcomes on NCLEX–RN.
7 Purpose of the Study The purpose of this quantitative research study is to determine the effectiveness of the Elsevier HESI online remediation at increasing E 2
scores and to examine the role of program consequences at increasing E 2
scores. A quantitative research ex post facto research design was chosen because the instrument for data collection was used from the eight Elsevier HESI validity study (V8S). According to Creswell (2008), the quantitative ex post facto research desi gn is employed when the data for the research study has been collected retrospect ively. In addition, Creswell emphasized that an ex post facto design is used retrospectively and seeks to investigate possible cause-and-effect relationships by observing e xisting data and examining independent and dependent variables. For Research Question 1, “What is the correlation among scores on the Elsevier
HESI™ Exit Exam (E2) when nursing students used the Elsevier HESI™ online remediation resource before being administered the second version of the Else vier HESI™ Exit Exam (E²),” the dependent variable examined was the E² scores pre a nd post remediation. The independent variables for Research Question 1 were nursing progra ms that use the Elsevier HESI online remediation and those schools that do not use the Elsevier HESI online remediation. The Elsevier HESI online remediation wi ll vary and is customized to depending on individual scores and areas of weakness on the E². For Research Question 2, “What is the correlation between program consequences, such as course passage or grading the exam and the outcome of the Elsevier HESI™ Exit Exam (E²),” the dependent variable examined was the E ² scores for schools that employ program consequences. The independent variables for Researc h
8 Question 2 were the individual consequences that nursing programs employ when students do not succeed on the E². Examples of program consequences examined included attaching a grade to the E 2
or not allowing students to pass the course until a specific benchmark was met. Data analysis was performed to determine i f there is an increase in E 2
scores for those schools that employ program consequences. The participants will include 57 nursing programs from the 2007–2008 school years.
Rationale One rationale for investigating the effects of the online remediation prog ram is that experts in testing and remediation (Nibert et al., 2003) recommended studyi ng the effectiveness of remediation strategies to increase E 2
scores and NCLEX–RN pass rates. This research will examine the impact of online remediation on subsequent E 2
and this research study has not been examined in the literature. In addition, the results of examining the relationship of program consequences and online remediation’s impact on subsequent E 2
has the potential to benefit nursing students and nursing educators. Nursing educators and students may gain evidence that
supports or denies the use of program consequences. Also, nursing educators and students may benefit from the proposed research because current evidence supports that there is a direct relationship between high scores on predictor exams and the success rates of a graduates’ ability to pass the NCLEX–RN exam (Nibert et al., 2002; Nibert et al., 2003; Yoho et al., 2007).
9 Research Questions and Hypotheses The study addressed the following questions and related hypotheses: Research Question 1: What is the correlation among scores on the Elsevier HESI™ Exit Exam (E2) when nursing students used the Elsevier HESI™ online remediation resource before being administered the second version of the Else vier HESI™ Exit Exam (E²)? H01: There is no significant difference in Elsevier HESI™ Exit Exam (E²) sc ores for learners who use the Elsevier HESI™ online remediation. Ha1: There is a significant difference in Elsevier HESI™ Exit Exam (E 2 ) scores for learners who use the Elsevier HESI™ online remediation. Research Question 2: What is the correlation between program consequences, such as course passage or grading the exam and the outcome of the Elsevier HESI™ Exit
Exam (E 2 )? H02: There is no significant difference in Elsevier HESI™ Exit Exam (E 2 ) scores when program consequences are employed. Ha2: There is a significant difference in Elsevier HESI™ Exit Exam (E ²) scores when program consequences are employed.
Significance of the Study The goal of this quantitative research study was to add to the existing knowledge by providing a deeper understanding of the Elsevier HESI online remediation program
and it is effectiveness at increasing E 2
scores. The findings of this study may benefit nursing students, nursing schools and society. Nursing students may benefit from the
10 results of the study because the research will increase knowledge surrounding s tudent- centered approaches to remediation. Nursing programs and educators may benefit f rom the research results because the proposed research study will contribute to the existing body of knowledge and evidence surrounding online remediation programs. Finally and most essential, the nation may benefit by decreasing the shortage of qualifie d nurses who will lead the future to an improved healthcare reform. Although much has been written and researched about the effectiveness of E 2 , there is no known research on the impact of the Elsevier HESI online remediation program on E 2
scores. Educators and learners can benefit from the use of effective, student-centered, remediation methods that increase scores on the E 2
thereby increasing NCLEX–RN pass rates.
Definition of Terms Andragogy. “The art and science of how adults learn” (Knowles, 1980, p. 43). Elsevier HESI Exit Exam (E 2 ). A 160-item exam (150 scored items and 10 pilot items) comprehensive exam that is designed for administration near the compl etion of the curriculum to measure student preparedness for the NCLEX–RN. It is used to ident ify the strengths and weaknesses of the students and a possible need for remediation before taking the licensure exam. Elsevier HESI online remediation (formerly Evolve Reach Student Onlin e Exam Remediation). An online component designed to assist learners to remediate areas identified as needing improvement on the E².
11 End-of-program NCLEX–RN predictors. The format that includes the distribution of a comprehensive NCLEX–RN-style test to students who are either i n their last semester or in last year of a nursing program. National Council Licensure Examination–Registered Nurse (NCLEX–RN) .
The examination administered to graduates of RN programs for licensure in the United States. The exam is constructed and administered by the National Council of St ate Board of Nursing. Registered nurses . Persons that have undergone education at the diploma, associate, or baccalaureate level and meet qualifications to take NCLEX–RN .
Assumptions and Limitations The first assumption of the study was that students who take the E 2
and use the Elsevier HESI online remediation resource would show significant improvement in overall scores on subsequent E 2 . To this end, research supports that learners who meet or exceed a score of 900 on the E 2
have a 96% prediction of passing NCLEX-RN (Yoho et al., 2007). Another assumption is that the participants will respond honestly to the survey questions. Additionally, the assumption is that the online remediation meets the student’ s individual learning needs and is a preferred learning style. It is also assumed t hat the learner was comfortable using the online learning venue as a means for remedi ation. The participants included nursing programs in all states that used the E 2
exam and may not thoroughly reflect all remediation assessment programs; therefore, t he outcomes were specific to nursing programs that utilize the online remediation by Els evier HESI testing and remediation. Other associated variables may be present but will not be studied
12 include student variables such as GPA, individual study methods and demographic variables that may have a positive effect on increasing NCLEX–RN pass rat es.
Nature of the Study This study utilized a quantitative ex post facto design to address the impact of online remediation on the E 2
scores. The problems addressed in this research study are the impact of program consequences and online remediation on NCLEX–RN predictor exam scores. A convenience nonprobability sample of 66 nursing programs from the 2007–2008 school years were used for the study. The survey used for the study was the V8S that was mailed to all schools that used E 2
during that school year. A stratified random sample of schools in the diploma ( n = 4), ADN ( n = 36), and BSN ( n = 26) from the V8S from September 1, 2007, and August 31, 2008, was examined to determine if learners’ scores after online remediation were st atistically significant. In addition, data pertaining to program consequences was access ed and compared to determine if program consequences contribute to an increase in scores on the E 2 . The impact of the Elsevier HESI online remediation was assessed post remediation using a standardized testing program, the E 2 . The students’ scores of a second version of the E 2
were compared to learners who are required to complete online remediation with students who are not required to complete online remediation. The subsequent version of E² has statistical data to prove validity (Lewis, 2008; Morrison, e t al, 2004; Newman, Britt, et al, 1999; Nibert, et al, 2002; Nibert, et al, 2003; Yoho, et al, 2007; Young & Langford, 2011) and the exam blueprint aligns with that of the NCLEX–
13 RN. The researcher compared results of the second E 2
scores after students use the Elsevier HESI online remediation resource to the second E 2
scores of learners who did not use the online remediation. Survey questions that pertain to remediation methods of ADN, BSN, and Diploma programs were used to determine which nursing programs require remediation. Test - takers’ scores after the Elsevier HESI online remediation were access ed and compared. The students’ scores of a second version of the E 2
were compared to learners who were required to do online remediation with students who were not required to do online remediation. The research also compared program consequences to determine if pro gram consequences contributed to an increase in scores on the E 2 . This research is important because current evidence supports that there is a direct relationship between hi gh scores on predictor exams and the success rates of a graduates’ ability to pass t he NCLEX–RN exam (Nibert et al., 2002; Nibert et al., 2003; Yoho et al., 2007).
Organization of the Remainder of the Study There are four chapters remaining in the study. Chapter 2 provides a review of the
literature on the student-centered learning theories; theories on remediatio n in post secondary education, and the use of progression and predictor exams for NCLEX–RN success. Chapter 3 discusses the specific methodology for this study. Chapter 4 disc usses the data-collection processes and analysis. Chapter 5 discusses the implications of the study, results, conclusions, and recommendations.
CHAPTER 2. LITERATURE REVIEW
The purpose of this chapter is to review the literature as it pertains to remedia tion components to increase NCLEX–RN success in student-centered learning envir onments. The review of the literature reveals theories and models for learning in the 21s t century. In addition, this review will include interventions that promote success on NCLEX–R N, using predictors and progression exams for success in nursing programs, and methods of
remediation used for increasing scores on progression and predictor exams. Sea rches that were executed include the use of Capella University’s Electronic Journal Library, Google Scholar, CINAHL, Medline, Academic Search Premier, and ProQuest. Keywords use d for searches included theories for adult learning , twenty first century learners in college , predictors of success in nursing education , use of progression and predictor exams , NCLEX–RN remediation efforts in nursing programs , and NCLEX–RN success in nursing education .
Student-Centered Theories Understanding adult learning theories is an essential component to the preparing nursing students to be successful on the NCLEX–RN. The learning environment today has had a paradigm that has shifted from a teacher-centered learning environm ent to a student-centered learning environment (Billings & Halstead, 2008). Given that today ’s
15 learner is preparing to enter a work force that is infused with technology it s tands to reason that teaching methods will also need to change to accommodate the learning styles and needs of the 21st-century learner (Billings & Halstead, 2008; Dede, 2005; Pre nsky, 2004). Consistent with these themes are the adult learning theories that are the foundation for planning and administering education programs, creating engaging learning environments, and counseling adult learners (Cross, 1981; Knowles, 1980; Merriam, 2001). Specific theorists who emphasize the central idea that adults lea rn differently than children and assist the educator to tailor the learning envi ronment to meet the needs of today’s learner are adult learning theory (Knowles, 1980), character istics of the adult learners (CAL) model (Cross, 1981), and the neomillennial learning styl e (NLS) theory (Dede, 2005). Andragogy From a historic perspective, adult learning theory originated when studies examined the relationship between younger adult learners and older adult learner s to determine if older adults scored the same on timed tests. This phenomenon led to further research on how adults learn. Knowles (1980) defined andragogy as “the art and science of helping adults learn” (p. 43). Andragogical principles center on the basic assumption that adults are not children and therefore learn differently. Adults move across a continuum from depende nt on the educator to independent and self-directed. Other assumptions of the adult learning
theory include that adults draw from life experiences and bring these experie nces to the learning situation. Another assumption is that adults are willing and internall y motivated
16 to learn (Knowles, 1980). The main assumptions of the adult learning theory are that adults are mature, self-directed, and accountable for their own learning. Characteristics of Adult Learners (CAL ) Consistent with Knowles’s andragogical principles is the CAL model by Cross (1981). The CAL model shares underpinnings with adult learning theory (Knowles, 1980) in that Cross contended that adults need flexibility and are independent in their educational endeavors if they have the support that is needed to succeed. The CAL model emphasizes that physical, psychological, and social difference exists be tween learners and examines the situations in which the learning occurs. For example, whether a learner attends part time or full time, whether the learner enrolled voluntarily or invol untarily were a key factor in determining the level of participation in the learning ex perience (Cross, 1981). Neomillennial Learning Styles (NLS) Much of the earlier research on adult learning did not include the use of media- based learning tools as methods to teach adults. While Knowles (1975) referred to adult learners as self-motivated and independent, in 1975, most learning for nursing students occurred in the classroom and clinical setting. Today, nursing students and educa tors have technologies that foster the independent nature of adult learning. Technolog ies such as the computer, the Internet, media, and social networking are all tools that ar e currently used by learners and can be used by educators to meet learning needs and object ives. For this reason, new theories for learning are needed to incorporate the use of te chnologies and the Internet as a medium for learning. One such theory is the NLS theory (D ede, 2005).