NCLEX-RN Pass Rates and ADN Curriculum Models in NC

Introduction

In the years prior to 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 primary 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 percent of 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). By comparison, baccalaureate programs graduated 37 percent of the total, and diploma or hospital-based educational programs graduated 3 percent (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 Hispanic, African American, and Native American individuals pursuing nursing careers. The American Association of Community Colleges (AACC) estimates that 57% of non-diploma African American nursing 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 increased from 1995 to 2000 with respect to the overall associate-degree nursing population — this is especially true for African Americans, who made up 7.1 percent of all ADN graduates in 1995 and 12.6 percent in 2000. Hispanics constituted 4.2 percent in 1995 and 7.4 percent in 2000 (Teich et al.). Finally, community colleges educate most nursing professionals in rural areas: 73 percent of all nursing graduates in rural areas came from ADN programs (National Center for Education Statistics, 2000).

The following study investigates the factors that have contributed to a recent significant decline in the student pass rate on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) in the state of North Carolina. In addition, the study examines Associate Degree Nursing Curriculum Models and provides a brief discussion of the NCLEX-RN exam itself. It subsequently focuses on nursing curricula, workforce shortages, and worker dissatisfaction, reports the results of a literary review, describes the problem, and presents the study proposal.

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 an analysis of the entry-level performance of registered nurses. All graduates of nursing programs must pass the exam in order to practice as a Registered Nurse. The NCLEX-RN 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, and the results of the test are often interpreted as an indicator of program quality. The State Board of Nursing can deny approval of a program whose failing rate is considered too high.

About the NCLEX-RN

Prior to 1994, the NCLEX-RN was a five-part pencil-and-paper test. In 1994, it evolved into a single computerized examination. Scoring is pass/fail, based not merely on the number of questions answered correctly but also on 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. As a result, the national passing rate for first-time candidates declined to 84%. There has been a significant drop in passing rates 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 failed on their first attempt. With a decline in the number of first-time test takers passing the NCLEX-RN, the number of RNs entering the workforce is further reduced.

NCLEX-RN data also showed that passing rates for both ADN and baccalaureate-prepared candidates have dropped. A peer analysis of the Integrated Postsecondary Education Data System (IPEDS) revealed that the graduate pipeline is skewed by geographic location, with institutions in rural areas experiencing the largest decline in graduates, followed by large and small towns (National Center for Education Statistics, 1995, 2000).

Historically, nursing curricula have been structured around a "blocked" course content approach. There are two varieties of blocking. The most commonly utilized approach is to design a curriculum around specific practice settings such as maternity or pediatric nursing. The second approach constructs courses around body systems such as the respiratory or digestive systems. The advantages of the blocked content approach are that it organizes both teaching and learning, complements faculty assignments, and facilitates faculty course scheduling.

In the last decade, the integration of selected nursing phenomena throughout the curriculum has become the more widely accepted design. In this approach, faculty identify concepts that are core to nursing practice and then "thread" these concepts throughout the curriculum. Concepts are introduced early in an elementary format and built upon as the student progresses. The disadvantage of this approach is that there are no discrete boundaries for content, which could inadvertently eliminate key material. Additionally, an integrated curriculum does not always address the specific expertise of individual faculty members.

Nursing Curricula and Workforce Context

There has been a decline in NCLEX-RN scores both nationally and in North Carolina. What are the causes of this decline? What can community colleges in North Carolina do to improve the NCLEX-RN pass rate for ADN program graduates? If the pass rate for first-time test takers has declined, is this an indicator of program quality or of faculty ability to implement the curriculum? The fundamental product of a nursing program is a graduate who is competent, can think critically, and is successful on the NCLEX-RN examination.

There is a national shortage of registered nurses. According to the 2001 Occupational Outlook Handbook, the profession of Registered Nurse is the largest healthcare 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) — equivalent to one hospital-based RN vacancy for every 2,230 people in the United States. In North Carolina alone there are 92,525 licensed RNs alongside persistent vacancies. An unprecedented demand for nurses by 2010 is projected to 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. Although the number of practicing registered nurses increased from 2.1 million to 2.2 million between 1996 and 2000, the U.S. population grew from 265 million to 281 million during the same period, resulting in a 2 percent drop in the number of RNs per 100,000 persons (Bureau of Health Professions Division of Nursing, 1996, 2001).

The U.S. General Accounting Office (GAO) cites many reasons for the nursing shortage. The principal reasons 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). Sources of nurse dissatisfaction that create further impediments to recruitment and retention 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 studies. Most notably, a study conducted by the Federation of Nurses and Health Professionals (2001) revealed that 50 percent of currently employed RNs are considering leaving the field for reasons other than retirement. In addition, a study by the Nursing Executive Center (2000) found that 28 percent of nurses were frustrated with their jobs and that 51 percent of those surveyed were more frustrated in 2001 than in the two previous years.

A survey conducted by the American Nurses Association (2001) found that 55 percent of RNs and LPNs would not advise others to enter the nursing field, and 23 percent said they would actively discourage family and friends from entering it. This prevalent hostility is fairly exceptional among the health professions and has been a major factor in the profession's retention problems (Federation of Nurses and Health Professionals, 2001).

A study of 100 hospital administrators found that 55 percent acknowledged they target nurses more than any other employee group when determining retention strategy (Nursing Executive Center, 2000). By contrast, pharmacists — the second-largest healthcare employee group — were the focus of only 24 percent of retention efforts. The survey also showed that the turnover rate among hospital staff nurses nationwide grew from 12 percent in 1996 to 15 percent in 1999 (Teich et al.).

In the past decade, nurse educators have been challenged to think creatively when preparing future nurses (Adams et al., 2002). Increased health services, changing population demographics, and technical changes in education have all intensified demands on nurse educators preparing twenty-first-century nurses. "Innovation and change are touted as desirable for nursing education programs; before adopting trends or changes, faculty should examine research studies that undergird the innovations/changes" (Adams et al., 2002).