Predicting nursing student success on the HESI comprehensive nursing exit examination
TABLE OF CONTENTS Approval iii Acknowledgements iv Abstract v Table of Contents vi List of Tables ix Chapter I 1 Introduction 1 Statement of the Problem 7 Statement of the Purpose 9 Research Questions 9 Significance of the Study 10 Limitations of the Study 11 Definitions of Terms 12 Summary 12 Chapter II 14 The Nursing Shortage 14 Nursing Faculty Shortage 17 The NET as a Predictor 18 Reading Composite 18 Math Composite 18
vii Life Stressors 18 Learning style 18 GPA as a Predictor 19 Science course GPA 19 Nursing courses GPA. 21 Retention and Attrition 21 AAS programs 22 BSN programs 22 HESI Exit Exam 25 Summary 27 Chapter III 29 Introduction 29 Design of the Study 29 Participants 31 Instrumentation 32 Data Collection Procedure 34 Methodological limitations 35 Ethical considerations 36 Data Analysis 36 Research Questions/Hypotheses 37 Summary 38 Chapter IV 40 Introduction 40
Hypothesis 1 41 Hypothesis 2 43 Hypothesis 3 44 Hypothesis 4 45 Hypothesis 5 46 Summary 48 Chapter V 49 Introduction 49 Summary 49 Findings 51 Implications for Practice 53 Recommendations for future research 54 Conclusions 55 References 57
LIST OF TABLES
NUMBER PAGE Table 1 - H o 1
Table 2 - H o 2
Table 3 - H o 3
Table 4 - H o 4
Table 5 - H o 5
48 Table 6 - Supply and Demand for RNs, 2000-2020 64
Table 7 - 2008 - Number of Candidates Taking NCLEX Examination and Percent Passing, by Type of Candidate 65 Table 8 – 2007 Number of Candidates Taking NCLEX Examination and Percent Passing, by Type of Candidate 66 Table 9 - Recent NCLEX-RN Pass Rates for the TSU Associate of Applied Science Degree 67 Table 10 – Data Collection Tool 68
Introduction Predicting who will succeed in passing required examinations for nursing licens ure has been the topic of several studies (e.g., AACN, 2007, Nibert, 2006, Lengacher, 1990). This research will contribute to an understanding of the primary academic cha racteristics found in students who successfully complete a nursing program by passing the Hea lth Education Systems, Inc. (HESI) comprehensive nursing exit examination by the third attempt and graduating. The research conducted for this study examined pre-admission var iables to determine their effect on students’ performance on the HESI comprehensive nurs ing exit examination. If faculty are able to identify students who are likely to succes sfully complete the program prior to admission to the nursing courses, then attrition will be decreased and more nurses will be available to the nursing workforce upon graduation. Many studies have looked at the National Council Licensure Examination for Registered Nurses, or NCLEX- RN, licensing examination success (e.g. Neibert, 2006, Spahr, 2000, Lengacher, 1990) but none has evaluated the characteristics that indicate students’ likelihood of pass ing the HESI comprehensive nursing exit examination. Since passing the HESI comprehensive nur sing exit examination has already been validated as a predictor of NCLEX-RN succe ss (Neibert et al, 2006), information on the characteristics needed to pass the HESI comprehensive nursin g exit examination are also predictors of passing the NCLEX-RN examinati on, and may be used to help determine who should be admitted to the nursing program.
2 Tennessee State University (TSU) is an urban Historically Black Coll ege or University (HBCU) located in Nashville. TSU offers a variety of choices o f degrees for students entering the nursing program including (1) Associate of Applie d Science degree (AAS) – which can be completed in a minimum of two years (four semester s), (2) Bachelors of Science Degree in Nursing (BSN) – which can be completed i n a minimum of 4 years (8 semesters), (3) LPN-to-RN in either the AAS or B SN degree program. This involves completing all general education courses required by ei ther degree, as well as one year (three semesters) of nursing courses for t he AAS degree, then progression to the RN-to-BSN degree program. All of these educational tra cks require the students to pass the HESI exit examination by the third attempt or t he students will not graduate or be allowed to take the NCLEX-RN licensing examination. The student body in the School of Nursing is made up of traditional and non- traditional students, full-time and part-time, with many individual variables. Although there are major medical centers nearby and another major university a shor t distance away, the student body at TSU consists of students from areas distant to t he university, including many out-of-state or foreign students. There are also three distance sites for the nursing program – one at Volunteer State Community Colle ge (VSCC), 29 miles away in a suburban/rural area, and two in other locations in Nashville, at the Avon Williams campus (AWC), and on the Nashville State Technical Community College (NSTCC) campus (TSU Catalog, 2005-2007).The VSCC site also draws students from an even more distant rural part of the stat e, and many of those students seek to enter the nursing program. Many of the students on all
3 four campuses are the first persons in their family to attend or graduate fro m college, no matter their race or gender. Many of these students commute long distance s to attend college. They are mainly nontraditional students, in that they are older, ha ve families, work full or part-time, and spread out their education over a number of years
because of these other factors. At the time this study was conducted, there were three to four times the numbers of applicants for admission to the TSU School of Nursing than could be admitted. Applicants admitted were selected primarily based on their grade point average (GPA) at the time of admission, regardless of the courses completed, the
number of times they may have had to repeat a course to pass it, or the fact that the y may have earned degrees in another field. The nursing courses were offered on the Main campus and the three additional distance sites. The main campus had 108 qualified applicants for the Fall, 2007, semester and admitted 40 students. The Volunteer State Community College (VSCC) site in Gallatin had 150 qualified applicants and admitted 30 students. The Nashville State Technical Community College (NSTCC) site had 59 qualified applicants and accepted 20 students. Statewide, there is a severe shortage in qualified nursing faculty (Tenn essee Center for Nursing 2007).This is due to a variety of reasons, including the aging of the “Baby Boomers,” who increase the population needing nursing care, retireme nt of the aging members of the nursing workforce, increases in active nurses not working in patient care, and changes in the utilization of professional nurses. Accr editation requirements mandate that one instructor may have no more than 10 students in a clinical practice site (NLNAC 2005). Some hospitals or clinical agencies re quire that
4 only 6 students may be with each instructor. These requirements mandate a large pool of nursing faculty in schools of nursing. It is common for 30 to 80% of the students admitted to a nursing program to leave the program during the first year of clinical nursing courses (Mollan-Master s, 2008). This is due to a variety of reasons (MDA/ONW, 2004). However, the major academic reason fo r attrition is usually failure in the nursing courses. Since there is an acute shortage of pr acticing nurses, as well as an acute shortage of nursing faculty, admitting students who wil l successfully complete the program is a great concern. Faculty can not do much about students who leave the program due to personal reasons, such as illness, pregnancy, financial problems , family or work demands, or other reasons not related to academics, but there is an effort bein g made to assist academically “at risk” students to overcome problems that can b e helped by tutoring or other methods. Use of the Nursing Entrance Test (NET) Pre-Nursing entrance exam ination All students applying for admission to the TSU nursing programs, AAS or BSN, have to submit the results of the NET Pre-Nursing entrance examination. The
AAS program requires that the math and reading composite scores be 50 or better. The BSN program requires the math and reading composite scores to be 70 or better. Exceptions might be made if others variables, such as GPA, were extremely hig h. Other information available from the NET, such as learning style, life s tressors profile, or overall composite scores, were not considered for admission. However , at the time of this study, no scores on the NET were used to keep students out of the AAS nursing program (TSU catalog 2005-2007).
5 Use of the Health Education Systems Incorporated (HESI) nur sing exit exam at TSU
The HESI comprehensive nursing exit exam is given three times during the
students’ last year (2 nd year for AAS students, and 4 th year for BSN students). The first time is at the end of the first semester of the last year, and two times during the second semester of the last year. At the time of this study, s tudents had to achieve a score of 850 or better to pass this exam. A score of 900 is being c onsidered for passing starting in 2009. If a student does not achieve a passing scor e by the third attempt, that student is given an Incomplete grade for the last nursing course, and graduation is withheld until the student has completed remedial work and passed the examination. Students are allowed to participate in graduation and pi nning, but do not receive their diploma, and are not allowed to take the NCLEX-RN l icensing exam until they pass the HESI comprehensive nursing exit examination. T SU provides a four day State Board Review taught by an outside source on campus a fter graduation for all students. This is accepted as one form of remediation for t hose students who did not pass the HESI comprehensive nursing exit examination. Students may also pay for and take other State Board Reviews. HESI provides online tutorials the students may participate in during their last semester as we ll as after the semester is over. HESI also provides a very detailed written report on how student s did on the examination, including identifying which areas need additional remedia tion. There are faculty members in the School of Nursing who tutor students duri ng the summer, before additional opportunities for taking the HESI are offered. If t he students do not pass the examination by the end of the next semester, an F i s assigned for that course
6 and the students do not graduate at all. Very few schools of nursing w ill admit a student who has failed out of another nursing program. Although several different examinations had been used in the past, the HESI comprehensive nursing exit examination was selected as the exit exam of choi ce by the faculty in 2003. According to Nibert, et al, (2006), this exam is 98.46% accurate in predicting NCLEX-RN success. It also may be used to predict students’ ris k for failure on the licensing exam. When students fail the NCLEX licensing exa m there are negative implications for both the student and the school. The graduates have to pay a fee of $300 each time they take the NCLEX-RN licensing examination. T hey cannot obtain employment as a Registered Nurse until they pass the NCLEX-RN
examination. They usually have jobs waiting for them, which will be lost if they do not pass. Their student loans become due, with limited income to pay them back. Many students also have personal plans that must be delayed. The School of Nursing may lose its accreditation – both from the State Board of Nursing and from the National League of Nursing (NLNAC) if fewer than 85% of the students taking the NCLEX-RN examination do not pass on the first attempt. The Nursing Shortage Much has been written about the nursing shortage and its effect on patient care and the practice of nursing (NLN, November 4, 2003). The TSU School of Nursing experienced the effect of the nursing shortage in two ways – a shortage of qualified nursing faculty, and pressure to accept more students into the program t han the faculty can accommodate. This has affected the School in several ways. T he pressure to accept more students than the faculty can accommodate has made it
7 difficult to provide the students with the individual attention and tutoring that may be
needed by many of the students. The ratio of no more than ten students per instructor in a clinical area must be maintained for National League of Nursing and Stat e Board of Nursing Accreditation (NLNAC 2005). Many hospitals are now limiting sc hools of nursing to no more than six to eight students in a clinical area. Accreditatio n standards also require that all School of Nursing faculty have a minimum of a Master’s degree in Nursing. There are large numbers of nursing faculty m embers across the nation who are over fifty years of age. They will be retiring i n the next ten years or so. This has led to the prediction that there will be an even more severe shortage of qualified nursing faculty in the next decade (See Figure 1, AANC 2000, TBR 2007, CAN 2007). Statement of the Problem The severe nursing shortage has increased the demand for higher enrollment in Schools of Nursing. New ways to deliver nursing education are being implemented. It is essential that the students accepted into nursing programs are the ones most likely to succeed by completing the program and passing the HESI comprehensive nursing exit examination. There is an increase in the number of available distance education nursing programs. The Tennessee State Board of
Regents (2008) is offering a new Regent’s Online Degree Program (ROD P) AASN program that is to begin in January, 2009. TSU will be participating by accepting a group of 10 students into this program. There are currently over 100 applicants for the 10 openings available thru TSU. The TSU School of Nursing has had over 300 qualified applicants per year for the AAS program and over 60 qualified applicant s
8 per year for the BSN program. Only a few of these applicants could be admi tted to the programs because of a shortage of faculty, insufficient classroom spa ce, and increased demands for clinical sites. In the Fall of 2007, the applicants for the AAS program included 150 qualified applicants for 30 spaces at the VSCC campus site, 100 applicants for 40 spaces on the Main campus, 59 applicants for 20 spaces on the NSTCC site, and 30 applicants for the LPN-to-RN program on the AWC site. The BSN program had 59 qualified applicants for 40 spaces. Of the 40 students accepted at VSCC for Fall of 2007 thirteen (13) withdrew or failed by the end of the second semester. Of the 40 students accepted on the main campus 12
withdrew or failed at the end of the first semester and 6 more were lost by the end of the second semester. NSCC campus (n=20) and the AWC campus (n=25) did not lose any students by the end of the first year. A majority of the AAS applicants had completed the co-requisite courses. All of the BSN applicants had completed the prerequisite courses. This meant that they had been in the pipeline for several years before actually applying to enter the nursing program. Many had attended part-time, and believed that they would automatically be accepted i nto the program when they applied. There has been a relatively high attrition rate among students enrolled in the AAS and BSN nursing programs, which is fairly common in Schools of Nursing (Mollan-Masters 2008). With the current and projected nursing shortage (e.g. AACN, TBR, TCN 2000, 2007), it is critical that schools of nursing produce as many graduate nurses as possible who will pass the NCLEX-RN exam , and become practicing nurses. It is also vitally important to the School of Nur sing for its graduates to pass the NCLEX-RN on the first attempt. If less that 85% of first
9 time applicants fail the NCLEX-RN, the School of Nursing will be put on probation, and may eventually have to close, unless that pass rate improves quickly (Tennesse e Board of Nursing Rules and Regulations 2007). Statement of the Purpose The purpose of this study is to identify the characteristics of applicants most
likely to successfully complete the nursing program and pass the HESI comprehensive nursing exit examination, as well as the NCLEX-RN licensi ng examination. By determining the key academic indicators that most reliabl y contribute to the successful completion of the nursing program, attrition can be reduced and retention increased. Students who passed the HESI exit examination by
the third attempt are assumed to possess these characteristics. This woul d enable faculty to select students for admission who were most likely to successfull y complete the program and pass the HESI comprehensive exit examination by the third attempt. Research Questions The following research questions were influential in determining the direct ion of this study on predicting student success in the nursing program and on the HESI comprehensive exit examination. Research Question #1 : Are the components of the NET pre-nursing examination a predictor of student success on the HESI comprehensive exit examination? Research Question #2: Are student grades in Anatomy and Physiology I and II predictive of their success on the HESI comprehensive exit examination?
10 Research Question #3 : Are students who fail Anatomy and Physiology I and/or II and repeat the courses more likely to fail the HESI comprehensive exit exa mination than students who passed Anatomy and Physiology I or II on the first attempt?
Research Question #4 : Is the pre-nursing student’s cumulative admission GPA a predictor of student success on the HESI comprehensive nursing exit examination?
Research Question # 5: Does a score of 850 or better on the HESI comprehensive exit examination predict that students will pass the NCLEX-RN. Significance of the Study
The School of Nursing Self-Study completed for the NLNAC accreditation visit in 2002 revealed an attrition rate of 47% for the AAS degree program over a three year period from 2000 to 2002. If the admission committee could improve the screening methods of applicants for the nursing program by admitting students most likely to successfully complete the program, attrition could be significa ntly reduced. Currently the AAS program at TSU has a high percentage pass rate of the NCLEX- RN licensing examination for first time takers varying between 90-96%. T he BSN program was put on probation by the Tennessee Board of Nursing in 2006 due to low pass rates of 74% -83% (TSU Self-Study, 2002).They were removed from probat ion in 2007 when NCLEX-RN pass rates increased to 87 % (TSU Self-Study report, 2007). There is currently a critical shortage of nurses nationwide and abroad. (e. g. ONW 2004, TCN 2007, AACN 2006). In 2001 the Southern Region Education Board issued a RED ALERT for the shortage of nursing faculty, and offered financi al incentives to anyone who would pursue a Master’s degree in Nursing with the
11 intention of teaching in a School of Nursing after graduation (SREB 2001). The shortage is expected to get worse in the future as “Baby Boomers” age, retire , and require more nursing care (Mississippi Office of Nursing Workforce, 2004). T here are 46% of nurses who are over 45 years of age or older today, with fewer younger
nurses available to replace those who retire or quit (AACN 2006). At TSU, the majority of the full-time faculty is over 50 years of age, and several are in their sixties and seventies. Younger faculty members often only stay a year or two, and leave f or better paying and less stressful positions. In order to maintain accreditati on standards and give the students the best clinical preparation, there can only be 10 students for
each instructor in the clinical area (1:10 ratio) (Tennessee Board of Nurs ing Rules and Regulations 2007). If a school of nursing does not maintain accreditation, their graduates cannot sit for the NCLEX-RN licensing exam. Limitations of the Study Since this study was limited to TSU’s AAS and BSN programs, and to those students who completed one of these programs in May, 2007, the results may not be generalized to other nursing programs. Other conditions that prevent generalizat ion include the fact that TSU is an Historically Black College or Universit y (HBCU) located in an urban area. It is not representative of the majority of Schools of N ursing located in large universities nationwide. It is unusual for a university to offer A AS programs. In Tennessee it is more common for community colleges to offer the t wo year AAS degree. This study was limited to students accepted in the AAS and BS N nursing programs at TSU in August of 2005 and graduating in May of 2007. It included only students who took the NCLEX-RN for the first time in 2007. Only data
12 for AAS and BSN students graduating in May, 2007, was included in the study. Only select variables were included in the study. There were other variables that could have influenced the outcome, including non-academic variables. Only NET scores, cumulative GPA, Anatomy and Physiology grades and repetition of these courses, and HESI comprehensive nursing exit examination scores were included in t his study. This was a correlation study using multiple regression and inferential st atistics. Data was limited to information routinely kept by the School of Nursing and available in the student records. Teaching methods used in the courses vary by instructor and are unknown to the researcher. Also unknown are the tutorials by various faculty teaching in the courses, most student demographics, prior experience in health car e or related fields, motivation, and other variables that influence student success.
Definition of Terms Success on the HESI comprehensive nursing exit examination is defined as a score of 850 or better by the third attempt.
Summary This chapter presented information about the TSU School of Nursing and the current admission practices. The background of the reasons for this study was discussed. Current testing utilizing the NET pre-admission test and the HESI comprehensive nursing exit examination was described. Information concerning the
current and predicted shortage of nursing faculty and of practicing registe red nurses was documented. The problem of determining the best qualified applicants for admission to the School of Nursing was presented. The purpose of the study along with the significance and acknowledged limitations were discussed. Defi nitions of
13 terms were given. Chapter 2 presents an extensive literature review of r esearch by other schools of nursing on attrition and retention of nursing students.
CHAPTER II LITERATURE REVIEW
The Nursing Shortage The American Association of Nursing Colleges (AANC, 2000), the Tennessee Board of Regents (TBR, 2007), and the Tennessee Center for Nursing (TCN, 2007) conducted studies to project the supply versus demand for Registered Nurses in Tennessee from 2000 to 2020 (See Figure 1).The percent of active nurses not in patient care is based on the percentage of active nurses not working in direct patie nt care from the March, 2001, RN licensure file. Beginning in 2008, nursing demand outpaces supply. Some differences may be explained by increases in population and changes in utilization. The majority of the difference may be due to the agin g of the RN workforce. Nurses are not being replaced as they age and drop out of the workforce. At present (2008) the supply and demand are currently very close. Over time, demand will exceed supply. This gap becomes greater each year beginnin g in 2008. A total shortage of over nine thousand RNs is predicted by 2020. These studies (e.g. AACN, TBR, TCN 2000, 2007) also identified the critical shortage of nursing faculty, citing that 5,823 qualified applicants to nursing programs were denied admission in 2001 due to a combination of a lack of faculty, lack of clinical training sites, and lack of classroom space. The average age of nursing faculty nat ionwide is fifty-four years, so many will be retiring during the next ten years .Of the 1,666 nursing schools in the United States, the Southern Regional Education Board (SREB)
15 operates 491 nursing schools. The average age of graduates of doctoral nursing or programs in related fields is 46 years. Nursing faculty must have at least a Master’s degree in nursing. The trend is to require a doctorate. There are 971 nursing faculty
teaching without adequate credentials within the SREB. According to a Fact Sheet published by the American Association of Colleges of Nursing (April, 2008), by the year 2025 there could be a shortage of 500,000 Registered Nurses. Several factors contribute to this nursing shortage: insuff icient enrollment to meet projected demands, shortage of nursing school faculty which restricts nursing program enrollment, an aging population of current RNs, cha nging demographics which demands more nurses to care for an aging population, increased stress levels for practicing nurses due to the shortage of adequate staff pre cipitating heavy workloads, and high turnover and vacancy rates due to decreased job satisfaction and increased stress. This nursing shortage has a dramatic impact on quality of patient care. A staff shortage increases the RN’s workload (the nurse to patient ratio). Research ha s shown (AACN, 2008) that this results in increased patient mortality, failure to r escue, and increased length of stay, which compromises patient safety. Most agencies r eported that the nursing shortage limited the ability of the nurse to detect complica tions early, maintain patient safety, and collaborate with other health team members. It a lso results in an increased incidence of medical errors that otherwise could have been prevented. A study conducted by the University of Pennsylvania (2002), and reported in The Journal of the American Medical Association (2002), found that the risk of death for a surgical patient was increased by 7% for each additional patient added to a
16 nurse’s workload. Life-threatening complications are also less likely t o be discovered. As a result, many states are working on regulations mandating a nurse’s wor kload. However, this is difficult to legislate, since the acuity (seriousness) of a patient’s condition determines how many patients should make up a nurse’s workload. There is concern at the Federal level about the national nursing shortage. The
Nurse Reinvestment Act, proposed by Bill Capps (Bill number H.R.3487) was pass ed by the Senate in December, 2001,
and passed by the House on December 19, 2001. It “amends the Public Health Service Act to direct the Secretary of Health and Human Services to develop national and make grants to support State and local broadcast public service announcements promoting the nursing profession; Expands eligibility for the nursing loan repayment program to include service in private hospitals, State or local departments of public health, skilled nursing facilities, home health agencies, hospice programs, and ambulatory surgical centers, subject to certain restrictions. Authorizes the Secretary to provide nursing scholarships in exchange for nursing services in designated health facilities. Treats such scholarships as equivalent to those made under the National Health Service Corps Scholarship Program for repayment purposes, except as specified. Grants preference to applicants with the greatest financial need and/or a willingness to serve in geographic area s with nursing shortages and need. Authorizes appropriations for FY 2002- 2007. Requires the Comptroller General to study and report to Congress on: (1) any differences in nurse hiring practices between profit and