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NCleX-rN First-Time Passing Predictors

Elizabeth B. Simon, PhD, RN, ANP Susan Joseph, PhD, RN, CNE

n Abstract

The first-time passing rate in National Council Licensure Exam for Registered Nurses (NCLEX-RN) depicts the quality of a nursing program. Therefore, nurse academics must be engaged in educational research to identify predictors for passing the NCLEX-RN on the first attempt. Grounded on the application of general systems theory, this study investigated the predictability of academic variables in achieving first-time passing in the NCLEX-RN. Multiple logistic regression demonstrated the predictive ability of tests of essential skills (TEAS) and grade point average (GPA) toward the outcome. Pharmacology, leadership, and adult health nursing courses showed a statistically significant positive correlation with the first-time passing status. This study contributed to a substantial change: establishing a minimum score in the TEAS exam to progress to the clinical phase. Before this, the only requirement was that the students take the TEAS exam and send in the results.

Keywords: NCLEX-RN, first-time passing, predictor variables, clinical courses, nursing prerequisites, systems theory

Introduction

This ex post facto study was designed to identify predictors of success in the National Council of Licensure Examination for Registered Nurses (NCLEX-RN). The public and regulatory agencies evaluate the undergraduate nursing programs by the published NCLEX-RN first-time pass rate. Therefore, predictors of the NCLEX-RN first-time passing status pass/ fail were explored in the study and the results shared below as “predictors of a first-time pass in a baccalaureate program.”

Background

There is a high demand for registered nurses (RNs), and at the same time, not 100% of the graduates from the nursing program obtain RN licensure to begin their entry-level nursing practice. Nursing graduates are required to take the NCLEX-RN to ensure their minimum competence as entry-level practitioners. As health care becomes more complex, the National Council of State Board of Nursing (NCSBN) considers public safety a priority and periodically raises the passing standards. To meet such demands for nursing and healthcare quality and quantity, nursing programs must achieve a high pass rate. Therefore, nurse educators must research and explore evidence-based strategies to improve the NCLEX-RN pass rate. Educators should study the influential variables of educational success

Elizabeth B. Simon, PhD, RN, ANP School of Nursing, Alliance University, New York, New York

Susan Joseph, PhD, RN, CNE School of Nursing Montefiore Medical Center, New York, New York

and adopt policies to facilitate quality outcomes. With that idea in mind, the study was conducted to identify academic predictors contributing to the program’s outcome. The study used general systems theory (GST) to explore the predictors influencing the passing status.

Theoretical Framework

The application of general systems theory in education can be compared to an organism with input, throughputs, outputs, and feedback loops to accomplish its goals through profound learning, instructional design, and educational technology in the present-day milieu (Bertalanffy, 1969; CarrChellman & Carr-Chellman, 2020). The input becomes the personal system of students, such as motivation to learn, cognitive skills, manual dexterity, organization, and prioritization skills. The throughput is the interpersonal system that encompasses students and faculty in the clinical learning environment. This throughput influences the output, which is a licensure for effective clinical practice. When Kroposki et al. (2019) applied GST in their study, input was quantified as cumulative GPA, TEAS composite score, and interview scores. Throughput was mastery learning, active and collaborative learning, faculty resources, and other support systems. The feedback loops are remediation, and the output is the successful completion of the program. Throughput and feedback loops produce changes in the personal system of the student with knowledge, skills, and values. Thus, like a living organism, education influences, transforms, and maintains changes in personal, interpersonal, and social systems. In our study, we investigated the effect of input variables on the NCLEX-RN first-time passing status.

Literature Review

Input

Literature has a plethora of evidence that predictor variables influence the outcome of high NCLEX-RN first-time pass rate. However, it is difficult to isolate one single variable as the best predictor of student success. Therefore, a combination of variables can provide a reliable prediction approach (Al Alawi et al., 2020). The main predictors of success in nursing school as input are pre-nursing overall GPA, science GPA, and admission test scores.

Admission criteria are an input variable that influences the outcome, and there is evidence from past studies. Nursing programs use any one of the admission tests by these vendors: Health Education System Incorporated (HESI) admission exam, Test of Essential Academic Skills (TEAS), Kaplan Nursing Admission Test, or National League for Nursing Pre-Admission Exam (NLN PAX-RN). Robert (2018) affirmed a positive correlation between admission exams and first-time passing status. For example, the NCLEX-RN pass rate improved from 77.60% to 95.49% with a revised admission criterion, including the admission score requirement on HESI raised from 75.00% to 80.00% (Pullen, 2017). HESI exit exams given at the end of the program predicted first-time NCLEX-RN passing more than any other investigated variable (Johnson et al., 2017).

TEAS composite score is an average in English, reading, math, and science. In addition to the average or composite scores, researchers identified correlations between specific components of the TEAS exam and program success. TEAS Version V science component has correlated with fundamentals of nursing (Liu & Codd, 2018). However, Flowers and colleagues (2022) did not find TEAS composite scores to predict NCLEX-RN success; on the other hand, they found that a GPA of higher than 3.5 and an Assessment Technology Institute (ATI) TEAS B score above 60 predicted NCLEX-RN success.

Critical thinking (CT) scores are another specific input predictor for student success in the nursing program (Porter, 2018). In addition to program success, the above input variables influence first-year courses such as fundamentals of nursing, pharmacology, and health assessment (Gartrell et al., 2020; Kroposki et al., 2019). The study also found GPA to be the single factor that best predicted NCLEX-RN success; nevertheless, mentoring students with lower GPAs will enhance retention and assist in passing the exam on the first try (Havrilla et al. 2022). Overall preadmission GPA, entrance assessment scores, interview scores, and exit assessment scores were significantly correlated with nursing students’ success (Kroposki et al., 2019). Despite challenging input variables, appropriate mentoring as throughput will promote student success.

There were nonacademic gender factors that predicted first-time NCLEX-RN success. Banks and others (2022) at a historically Black college and university (HBCU) conducted a descriptive study. They found female students (93.15%) were more likely to pass the NCLEX-RN on the first attempt than males (82.61%). We need to explore further to determine whether these gender-based challenges correlate only to HBSU students or not.

Throughput

The input and throughput variables predict and influence the output: competent practitioners who can pass the licensure exam on their first try. The authors support Havrilla and others’ (2018) findings that even if the input variables are not optimal, instructional and technological resources may enhance learning and test-taking. The throughput is a support system that includes faculty, technology, and pedagogical resources. Institutional and program resources, such as mentoring, are also components of throughput. There is sparse literature on the impact of qualitative variables on throughput. Currently, to improve diversity and inclusion, many nursing programs adopt holistic admission strategies, taking into account considerations such as the life experiences of candidates and interview results as qualitative measures in the admission decision.

Students require systematic orientation to deep learning, quality and safety education for nurses (QSEN) competencies, adoption of NCLEX-RN review book as a required textbook, adaptive quizzing, review of the wrong answers in course exams and standardized exams, and remediation. Wallace (2021) recommended a criterion-based proactive curriculum, active learning modalities, and implementation of problemsolving strategies throughout the program to improve outcomes. Faculty mentoring has a significant impact as a throughput measure. Stuckey and Wright (2021) shared how mentoring by the faculty through email, texts, and messages from commencement day until the students took the NCLEX-RN influenced the exam performance positively. Faculty mentors guided the graduates and emotionally supported them throughout their preparation. Therefore, developing, monitoring, and evaluating a comprehensive mentoring program must be a strategy in nursing schools.

In addition to mentoring, Sanderson et al. (2021) studied the concept of learning. They explored social determinants of learning and developed a holistic support system to improve achievement gaps based on social and economic status. Students who spoke English as an additional language face specific challenges to timely NCLEX-RN completion and success, while nontraditional students, such as those over the age of 25 or obtaining their second degree, may have successful outcomes (Spurlock et al., 2019). Chamberlain University, with 59% of its student population hailing from diverse backgrounds, instituted a language and social support environment to reduce financial and psychological stress that can hinder learning. This measure aims to promote equitable education in nursing. Mindfulness training was also incorporated in the first nursing class to enhance the overall psychological health of the students (Petges, 2019). In addition, virtual and high-fidelity simulation, NCLEX-RN exam preparation using delegation and prioritization questions, and exam blueprints and test item analysis evaluation by annual curriculum committee review are other measures that enhance quality throughput.

Retention strategies are throughput factors that include a professional education program and academic support. Meehan and Barker (2021) found that a prescribed remediation protocol helped six cohorts achieve the required score in a predictor exam, demonstrating increased likelihood of passing the NCLEX-RN. There is a significant difference in predictor exam scores among those who were in a remediation program and those who were not in a remediation program.

This strategy resulted in 100% graduation and passing NCLEX-RN on the first attempt (Murray et al. 2016). Davis and Morrow (2021) explored faculty experience and recommended that the nursing faculty assume counselor and leadership roles in encouraging self-accountability in students to achieve better NCLEX-RN outcomes. In an older article, Bonis et al. (2007) recommended strategies such as assessment testing, independent studies, and simulated NCLEX-RN examinations to improve NCLEX-RN first-time pass rates. Czekanski and colleagues (2018) emphasized the value and effectiveness of a tutoring and a retention coordinator (TRC) as throughput factors improving the NCLEX-RN pass rate from 64.86% to 94.29% with cognitive behavioral techniques, content review, and test-taking strategies. Such a comprehensive approach to NCLEX-RN success should start from a program’s beginning and progress until after graduation. Successful outcomes are based on the collective effort of students, faculty, and administration.

Additionally, specific clinical courses influence the successful program completion and first-time passing status outcomes. Clinical courses are throughput variables. Banks and others (2022) did a retrospective descriptive study and found that academic predictors of first-time NCLEX-RN success were final course grades in Adult I, Adult II, or Child Health. There was 100% success for students who earned an A in Adult I, Adult II, or Child Health. Many nursing programs use predictor exams to determine the learning in clinical courses (throughput) and graduation status (output). The results of the predictor exams are influenced by the content knowledge of the clinical courses. Test-taking and critical thinking skills are essential factors that influence outcomes. Gillespie and Nadeau (2019) found a strong correlation between the Kaplan Integrated Exam score and the output.

Wilson-Anderson identified three variables contributing to nursing students’ first-time passing status: (a) nursing content knowledge, a principal component; (b) test-taking skills; and (c) external variables that affect the learners against their optimal performance (2022). Quinn and colleagues (2018) added critical thinking skills, in addition to test-taking skills and psychological well-being, as an essential component of NCLEX-RN success. A qualitative study on students’ perspectives for NCLEX-RN preparation showed that having a study plan, note-taking, staying focused, commitment, and constant practice of NCLEX-style questions were essential variables to passing NCLEX-RN on the first attempt (Joseph, 2021). Group learning among nursing students is a common practice on many campuses. Yet, Lown and Hawkins (2022) found a negative correlation between group learning and NCLEX-RN success.

All graduates should be prepared to be successful on NCLEX-RN. Therefore, finding at-risk students and implementing a timely intervention is another faculty role in nursing education. The input and throughput components influence the output: program completion and licensure. Many nursing programs use predictor exams to determine graduation status the output.

Purpose of the Study

Purpose of the study is to determine academic predictors of firstattempt outcomes pass/fail on the NCLEX-RN and statistically significant correlation with specific courses.

research Questions

What academic variables are predictors of first-attempt outcomes pass/fail on the NCLEX-RN for newly graduated nurses?

What is the relationship between first-attempt pass rates on the NCLEX-RN and the specific courses?

methods & Design

A retrospective quantitative study investigated variables influencing NCLEX-RN success pass/fail of 118 students in the nursing program located in the northeastern United States. Data collected included the pass/fail results of students’ first-time NCLEX-RN and students’ academic scores for various courses they had taken leading up to the NCLEX-RN. Correlation coefficients were computed between the score variables in an exploratory manner. Pearson correlation coefficients were computed between the two continuous variables and point-biserial correlation coefficients between a continuous variable and a dichotomous variable. A simple logistic regression model was fitted to data to study each score variable’s predictability of the pass/fail results of the first-time NCLEX-RN pass rate. A multiple logistic regression model was also fitted to data to check those variables identified as significant with preceding simple logistic regression as a group predicting the pass/fail results for the first-time NCLEX-RN pass rate. IBM SPSS Statistics 27 was employed for all the analysis. Statistical significance was evaluated with α = 0.05.

Sampling

A bachelor of science (BS) in nursing program in the northeast collected academic data from the sample of 118 transcripts of the candidates who took the exam in 2018, 2019, and 2020 from the program. All letter grades in the transcripts were converted to a percentage score by taking the midpoint of that grade range. All transfer course grades were assigned a score equivalent to letter grade B as that was the minimum requirement for a course to be transferred. Any transcript with incomplete information was not included in the study. The academic variables in this study were course grades for prerequisite science courses microbiology, chemistry, anatomy, and physiology I & II, pathophysiology) and nursing courses (Introduction to Nursing (NURS 102), Adult Health Nursing I & II (NURS 310, NURS 360), Pharmacology in Nursing (NURS 315), Maternal and Child Health Nursing (NURS 410), Community Health Nursing and Population Health (NURS 421), Mental Health Nursing (NURS 461), Research in Nursing (NURS 430), Nursing Capstone (NURS 480), and Leadership in Nursing (NURS 470)). The scores of nursing entrance exams were taken from the ATI database and total GPA from the transcripts. Data were entered in the Excel spreadsheet, and the researcher deleted the student identifiers. This study was granted an exemption from IRB approval as this study involved academics documents alone without any human participants. In addition, study methods affirmed measures to maintain student confidentiality.

Findings

Exploratory correlation analysis found that higher TEAS scores and GPAs were significantly correlated with the first-time passing of NCLEX-RN. Among the nursing courses, NURS 315 (Pharmacology in Nursing), NURS 310 (Adult Health Nursing I), and NURS 470 (Leadership in Nursing) demonstrated a statistically significant positive correlation with the firsttime passing of NCLEX-RN. None of the prerequisite science courses were significantly correlated with the first-time passing of NCLEX-RN (not shown in tables). Results of simple logistic regression analysis indicated that the first-time passing of NCLEX-RN was significantly associated with TEAS, GPAs, NURS 315, NURS 310, and NURS 470 (see Table 1). TEAS scores predicted better first-time passing of NCLEX-RN. Pharmacology was the second important course with predictor ability. Multiple logistic regression with all those individually significant predictors in a single model demonstrated that

TEAS and NURS 315 were the most important predictors of the first-time passing of NCLEX-RN (see Table 2).

TEAS exam scores may reflect test-taking strategies, decision-making capacity, and critical thinking ability. In addition, the predictive power of Course 315, Pharmacology (Nagelkerke R2 20.9%, p-value < 0.001) was interesting to the faculty. This significant finding places Pharmacology in Nursing as an essential course that mandates a review of teaching-learning methods, content, evaluation, and instruction. The predictive ability of the TEAS score (Nagelkerke R2 16.8%, p-value 0.002) was a desirable finding for implementing changes.

With all five variables put together, the multiple logistic regression model accounts for 27.1% of the variability in the passing or failure of NCLEX-RN.

For every additional point increase of TEAS, the odds of passing NCLEX-RN increases by 4% (95% CI: 1%, 8%).

For every additional point increase of Nursing Course 315, the odds of passing NCLEX-RN increases by 19% (95% CI: 5%, 34%).

Conclusion/Implication

The nursing department decided that the input variable (TEAS score) and throughput variables should be strengthened based on the results. The

NCLEX-RN First-Time Passing Predictors university did not have a minimum TEAS score requirement for admission. Nursing recommended changes in admission strategies beginning from Fall 2022, requiring a minimum score to enter the nursing program. The university approved this recommendation. Likewise, the throughput and feedback loops of the NURS 310 first adult health nursing course, NURS 315 pharmacology course, and NURS 470 leadership course need to be reevaluated for concepts, course delivery, instructional methods, and content to impact the output.

Among the nursing courses, N urS 315 (Pharmacology in Nursing), N urS 310 (Adult Health Nursing I), and N urS 470 (leadership in Nursing) demonstrated a statistically significant positive correlation with the first-time passing of NCleX- r N.

Educators must select effective, accurate, cost-effective admission tools to screen for qualified nursing candidates. Liu et al.’s (2018) study also showed similar results that utilizing content areas such as mathematics, reading, and English in conjunction with science contributes significantly to predicting early nursing school success.

Limitations Of The Study

Nonacademic factors such as age, ethnicity, transfer status, gender, and socioeconomic status were not included. Ten transcripts needed to be excluded because of the incomplete unavailability of corresponding TEAS scores.