1997, the average pass rate for first time test takers on the NCLEX-RN was 93%. Since 1997, the national average pass rate on the NCLEX-RN has declined to 83.8% (National Organization for Associate Degree Nursing, 2002). The pass rate for the state of North Carolina and many other states has also declined in recent years.
Community colleges are the prime educators of new registered nurses in the United States. In 1997, 701 community colleges awarded 41,258 associate degrees in nursing (National Center for Education Statistics 1997). The combined ADN graduate pool constituted 60% of the U.S. graduates who took the NCLEX-RN exam in 2000,and these graduates represent the largest group of nurses entering the profession (National Council of State Boards of Nursing 2001). On the other hand, baccalaureate programs graduated 37% of the total; and diploma or hospital-based educational programs, graduated 3%.(Teich, et al.)
In addition to educating the majority of nurses entering the field, ADN programs provide important opportunities for mature students and students from minority communities. Community colleges are the institutions of choice for entering into nursing for Hispanic, African-American, and Native American individuals. The American Association of Community Colleges (AACC) estimates that 57% of non-diploma African-American graduates were educated in associate-degree programs in 1997. Hispanic and Native American nursing graduates also received associate degrees at even higher percentages than African-Americans. The AACC also reports that the comparative representation of each of these minority groups has increased from 1995 to 2000 with respect to the overall associate-degree nursing population, this is especially true for African-Americans who make up 7.1% of all ADN graduates in 1995 and 12.6% of all ADN graduates in 2000. Hispanics constituted 4.2% in 1995 and 7.4% in 2000. (Teich, et al.) Lastly, community colleges educate most of nursing professionals in rural areas: 73% of all nursing graduates in rural areas came from ADN programs (National Center for Education Statistics 2000).
The following study will investigate those factors, which have contributed to a recent significant decline in the student pass rate on the National Council Licensure Examination for Nurses (NCLEX) in the state of North Carolina. In addition, the study will also examine Associate Degree Nursing Curriculum Models. The study will provide a brief discussion of the NCLEX-RN exam. Subsequently, the study will focus on Nursing Curriculums, Workforce Shortages and Worker Dissatisfaction.
The discourse will then report the results of a literary review and describe the problem. Finally the study shall present the study proposal.
About the NCLEX-RN
The National Council of State Boards of Nursing, created the National Council Licensure Examination for Registered Nurses (NCLEX-RN). The structure of the examination is based on the outcome of an analysis of the entry-level performance of registered nurses. All graduates of nursing programs must pass the exam in order practice as a Registered Nurse. The NCLEX-RN is the test, which attempts to ensure minimum levels of safety on the part of the practicing nurse to the public (Houchin, 1994). Nursing programs are always apprehensive about their graduates' performance on the NCLEX-RN. The results of the test are often interpreted as an indicator of the nursing program's quality. The State Board of Nursing can deny approval of a program for a failing rate, which is considered too high.
Prior to 1994, the NCLEX-RN was a five-part pencil and paper test. In 1994, the NCLEX-RN evolved into a single computerized examination. The scoring of the examination is pass/fail, which is based on not just the number of questions answered correctly but also the level of difficulty of the questions answered correctly.
In 1997, the national passing rate for first time test takers was 91%. In 1998, the National Council of State Boards of Nursing established a higher passing standard. Nationally the passing rate for first-time candidates has declined to 84%. There has been a significant drop in passing rates for NCLEX-RN since 1994. It is also documented that repeat takers of the NCLEX-RN have a significantly reduced chance of successfully passing the test if they fail on their first attempt. With a decline in the number of first time test takers successfully passing the NCLEX-RN, the number of RN's entering the workforce is further reduced.
The NCLEX-RN data also showed that the passing rates for both ADN and baccalaureate-prepared candidates have also dropped (Graph appears in Appendix 5 Figure 5). A peer analysis of the Integrated Postsecondary Education Data System (IPEDS) revealed that the graduate conduit is slanted in regard to geographic locations. Institutions in rural areas experience the largest decline in graduates, followed by large and small towns (National Center for Education Statistics 1995,2000)(Figure 6).
Historically, nursing curriculums have been structured in the 'blocked' course content approach. There are two approaches to blocking content. The most commonly utilized approach is to design a curriculum around specific practice setting such as maternity or pediatric nursing. The second conceptual blocking scheme is to construct courses around body systems such as respiratory or digestive systems. The advantages of blocking course content approach to curriculum design is that allow organization to both teaching and learning. It complements faculty assignments and facilitates faculty course assignments.
In the last decade, the idea of selected nursing phenomena integrated throughout the curriculum has become the more appropriate design. In this approach faculty identify concepts, which are core to nursing practice and then integrate or "thread" these concepts throughout the curriculum. These concepts would be introduced early in the curriculum in an elementary format and then as the student progresses through the curriculum these concepts would be built upon. The disadvantage to this approach to curriculum design is that there are no discrete boundaries for content, which could inadvertently eliminate key aspects from the curriculum. Secondly, integrated curriculum does not often address the expertise of the faculty.
There has been a decline in the NCLEX-RN scores nationally as well as in North Carolina. What are the causes or reasons for this decline? What can the community colleges in North Carolina do to improve the NCLEX-RN pass rate for graduates of ADN programs? If the pass rate for NCLEX-RN first time test takers has declined, is this an indicator of the quality of the program or the faculties' ability to implement the curriculum? The product of a nursing program is to produce a graduate who is competent and can critically think and be successful on the NCLEX-RN examination.
There is a national shortage of registered nurses (RN). According to the 2001 Occupational Outlook Handbook, the profession of Registered Nurse is the largest health care occupation with over 2, 700,000 jobs (National Organization for Associate Degree Nursing, 2002). The American Hospital Association (AHA) reports that there are currently 126,000 vacancies for RNs in U.S. hospitals nationwide (AHA 2001). This number adds up to one hospital-based RN vacancy for every 2,230 people living in the United States. Currently in the state of North Carolina there are 92,525 licensed RN's and ____vacancies. An unprecedented demand for nurses by 2010 will exceed the available supply (Thompson, 2001).
Seventy-five percent of all hospital personnel vacancies are for nurses, and the AHA describes the nursing shortage as "the most critical manpower problem facing hospitals across America. It is the underlying cause of hospital bed closures, cancellations of elective surgeries, and diversions of ambulances from emergency rooms. It threatens to affect every American needing medical care "(AHA 2001). Critical care medicine and emergency services have experienced the greatest shortage of hospital-based RNs. Workforce shortages of hospitals are characteristic of an overall deterioration of the nursing population. The number of practicing registered nurses increased from 2.1 million to 2.2 million between 1996 and 2000. Though, during that same period, the U.S. population increased from 265 million to 281 million resulting in a 2% drop in the number of RNs per 100,000 persons during that four-year span (Bureau of Health Professions Division of Nursing 1996,2001)
Nursing Workforce Shortage
The U.S. General Accounting Office (GAO) cites many reasons for the nursing shortage. The principal reasons for the shortage are recruitment and retention problems associated with an aging nursing workforce, intense workloads, insufficient staffing, increased use of overtime, deficiency of support staff, and poor wages (GAO 2001). There are several sources of nurse dissatisfaction that create impediments to the recruitment and retention of nurses. These sources include: reduced contact with patients, higher patient acuity, increased workloads, undesirable shift work, loss of independence, insufficient stimulation, uncertain career options, and lack of job security (AHA 1999).
Nurse dissatisfaction with the profession has been the subject of investigation in several of studies. Most notably is the study conducted by the Federation of Nurses and Health Professionals (2001). This study revealed that 50% of currently employed RNs are considering leaving the field for reasons that do not include retirement. In addition, a study by the Nursing Executive Center (2000) found that 28% of nurses were frustrated with their jobs and that 51% of those surveyed were more frustrated in 2001 than in the two previous years.