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1 ONLINE CASE STUDIES: HESI EXIT EXAM SCORES AND NCLEX-RN OUTCOMES ANNE YOUNG, EDD, RN, GLORIA ROSE, PHD, RN, FNP-BC, AND PAMELA WILLSON, PHD, RN, FNP-BC, CNE Using data obtained for the 7th HESI Exit Exam (E 2 ) validity study, the value of Elsevier's online case studies in assisting students to prepare for the E 2 and the National Council Licensure Examination for Registered Nurses (NCLEX-RN) was investigated. Of the 137 randomly selected of nursing, 72 (52.55%) participated in the study. The student sample consisted of 4,383 students from associate degree, baccalaureate, and diploma of nursing. Findings indicated that the mean E 2 score and the NCLEX-RN pass rate were significantly higher for students attending that used the case studies than they were for students attending that did not use the case studies. Descriptive data indicated that the case studies were most often used for remediation and examination preparation. (Index words: Case study; HESI Exit Exam; NCLEX-RN outcomes) J Prof Nurs 29:S17 S21, Elsevier Inc. All rights reserved. SEVEN PREVIOUSLY PUBLISHED studies indicate that Elsevier's HESI Exit Exam (E 2 ) is a highly accurate predictor of success on the National Council Licensure Examination for Registered Nurses (NCLEX- RN) (Adamson & Britt, 2009; Lauchner, Newman, & Britt, 1999; Lewis, 2005; Newman, Britt, & Lauchner, 2000; Nibert & Young, 2001; Nibert, Young, & Adamson, 2002; Young & Willson, 2012). Consequently, many of nursing use the E 2 as a predictor of students' preparedness for the licensure examination and as a guide for students' remediation needs. Numerous subject matter scores reported by the E 2 provide students with the information they need to focus remediation Professor, Texas Woman's University, College of Nursing, Houston, TX. Clinical Assistant Professor, Prairie View A&M University, College of Nursing, Houston, TX. Associate Director of Education, Michael E. DeBakey VA Medical Center, Houston, TX. Disclosure statement: Dr. Young and Dr. Rose have participated in research activities and received presentation honoraria from HESI Review & Testing within the past 3 years. Dr. Young serves as Chairperson of the Research Advisory Board for HESI Review & Testing. Dr. Willson was employed by HESI Review & Testing at the time this research was conducted. Address correspondence to Dr. Young: Texas Woman's University, College of Nursing, 6700 Fannin, Houston, TX eyoung@ mail.twu.edu /12/$ - see front matter efforts that address their particular learning needs. However, methods used to prepare students for the licensure examination and to remediate academic weaknesses identified by the E 2 so that candidates can achieve first-time success on the NCLEX-RN have not been adequately researched. A plethora of NCLEX- RN review books designed to assist students in reviewing content presented throughout the nursing curriculum are available for purchase. Yet, knowledge of content alone is not sufficient to achieve acceptable E 2 scores, pass the NCLEX-RN, and perform competently in the clinical area. Students and new graduates must also be able to apply nursing content and concepts to specific clinical situations and use critical thinking skills to solve clinical problems. Review of the Literature Case studies have long been used as a teaching method in business, law, and medicine because they provide an effective means of applying content and assisting students to develop problem-solving skills (Delpier, 2006). The use of case studies for teaching is generally considered superior to lectures in promoting learners' critical thinking skills, and students report a preference for interactive teaching strategies over didactic methods (Kim et al., 2006). Interestingly, despite students' preference for interactive teaching strategies and faculties' belief that case studies are superior to didactic teaching Journal of Professional Nursing, Vol 29, No. 2S (March/April), 2013: pp S17 S21 S Elsevier Inc. All rights reserved.

2 S18 YOUNG ET AL methods, little or no difference has been found in terms of students' learning outcomes when comparing the use of case studies and didactic teaching strategies (Beers, 2005; Costa, van Rensburg, & Rushton, 2007; Lauver, West, Campbell, Herrold, & Wood, 2009). However, studies that compared teaching methods could have been affected by the methods used to evaluate learning outcomes, which were usually traditional tests that measured knowledge of content, rather than exams designed to measure critical thinking. The E 2 and the NCLEX-RN, both of which are designed to measure critical thinking within the discipline of nursing, might be a better measure of the effectiveness of case studies in terms of students' learning outcomes. The use of case studies as a teaching strategy in nursing has been reported to promote critical thinking, develop students' clinical reasoning skills, and enhance students' problem-solving abilities (Dowd & Davidhizar, 1999). With the advent of instructional technology, innovative teaching strategies have been developed to assist students in achieving curricular and licensure success using self-paced learning opportunities. The online case studies provided by Elsevier are self-paced learning tools designed to assist students with the application of nursing knowledge and concepts in clinical situations, and as such, they are believed by many faculties to be an effective teaching strategy in helping students prepare for the E 2 and the NCLEX-RN. Schools of nursing may purchase a license to use the Elsevier case studies, which are marketed as patient situations accompanied by critical thinking questions that help students learn to manage complex patient conditions and make sound clinical judgments. However, limited research has been conducted to study the effectiveness of these case studies as a teaching tool and/or a remediation resource. Mihal (2006) is the only study completed to date that has investigated the effectiveness of Elsevier's online case studies. Using data obtained from Elsevier's database, Mihal divided into two groups: those that were licensed to use the case studies and those that were not licensed to use the case studies. Then, the mean E 2 scores for these two groups were compared. The mean E 2 score for the 1,544 students who attended the 34 of nursing that were licensed to use the case studies was , and the mean E 2 score for the 21,241 students who attended the 344 of nursing that were not licensed to use the case studies was A t test for two independent samples was used to compare the mean E 2 score of students who attended that were licensed to use the case studies with the mean E 2 score of students who attended that were not licensed to use the case studies. Findings indicated that the mean E 2 score for those who attended that were licensed to use the case studies was significantly higher (t = 9.979, P.000) than the mean E 2 score for students who attended that were not licensed to use case studies, thereby suggesting that Elsevier's online case studies positively affected students' E 2 scores. This study was designed to verify Mihal's findings regarding the E 2 scores of students with and without access to case studies. However, since the Mihal study was completed, case studies' licenses have become a component of several testing packages, and current access to them does not necessarily mean that they are being implemented as a teaching strategy. This study determined users and nonusers of case studies based on deans' and directors' reported use of the case studies, rather than merely having a license to use the case studies. For the purpose of this study, two terms were defined: (a) case studies Elsevier's online case studies that were licensed for use to of nursing; and (b) users of case studies students who attended of nursing where deans and directors identified their school as a user of the case studies. Specifically, the purpose of this study was to (a) determine if E 2 scores of students who used the case studies differed from E 2 scores of students who did not use the case studies, (b) determine if NCLEX-RN outcomes of candidates who used the case studies differed from NCLEX-RN outcomes of candidates who did not use the case studies, and (c) describe the methods used to implement the case studies. Methodology A nonexperimental, descriptive design was used to compare E 2 scores of students who used Elsevier's online case studies with E 2 scores of students who did not use the case studies. As part of the seventh E 2 validity study (S7), data were obtained from deans and directors at 72 randomly selected of nursing that administered the E 2 between September 1, 2006, and August 31, 2007 (Young & Willson, 2012). These participating deans and directors were asked to complete the S7 Participant School Survey, an electronic instrument that requested information regarding NCLEX-RN outcomes and use of the case studies. Additionally, data obtained from the three questions on the S7 Participant School Survey regarding case study implementation methods were used for descriptive purposes. Instrumentation Two instruments were used to obtain data for this study: the E 2 and the S7 Participant School Survey. The E 2 consists of 160 test items, 10 of which are pilot items that are not scored. It is a comprehensive exam that is administered to students near the completion of the nursing curriculum to measure their preparedness for the NCLEX-RN. The test items are written using a critical thinking model described by Morrison, Nibert, and Flick (2006) and require clinical nursing judgment to determine the correct answer. Morrison, Adamson, Nibert, and Hsia (2004) described the reliability and validity of the E 2. A reliability estimate or Kuder Richardson Formula 20 (KR20) is calculated for every E 2 prior to its administration and is based on item analysis data obtained from all previous uses of the test items contained in the exam. The mean estimated KR20 for the E 2 s administered during the study period was 0.926

3 ONLINE CASE STUDIES S19 Table 1. Description of Schools and Students by Program Type and HESI Case Study Use of of students Program type ADN 45 2,557 BSN 22 1,617 Diploma Total 72 4,383 HESI case study use Used the case studies 24 1,597 Did not use the case studies 48 2,786 Total 72 4,383 (Elsevier's HESI database, August 2011). Criterionrelated validity of the E 2 has been established by the seven validity studies that have been conducted over the past 12 years, indicating that the E 2 is between 96.36% and 99.16% accurate in predicting NCLEX-RN success (Adamson & Britt, 2009; Lauchner et al., 1999; Lewis, 2005; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002; Young & Willson, 2012). The S7 Participant School Survey consisted of multiple-choice items with open comment fields. Data obtained from this instrument were used to determine students' outcomes on their first attempt at taking the NCLEX-RN and to glean descriptive data regarding strategies used to implement the case studies. All identifying information was removed prior to providing data to the researchers regarding NCLEX-RN pass rates and case study implementation methods. Findings Nursing were randomly selected to participate in S7, and of the 137 selected for participation, 72 (52.55%) responded to the Participant School Survey. Of the 72 responding nursing, 45 (62.50%) were associate degree (ADN) programs, 22 (30.56%) were baccalaureate (BSN) programs, and 5 (6.94%) were diploma programs. The total student sample consisted of 4,383: 2,557 (58.34%) ADN students; 1,617 (36.89%) BSN students; and 209 (4.77%) diploma students. Of the 72 participating, 24 (33.33%) reported that they used the Elsevier online case studies within their school of nursing, and 48 (66.67%) reported that they did not use the case studies. Of the total 4,383 Table 3. NCLEX-RN Outcomes of Students Who Attended Schools That Used HESI Case Studies and Students Who Attended Schools That Did Not Use HESI Case Studies HESI case studies Students attending that used the case studies Students attending that did not use the case studies Total (%) passed NCLEX-RN (%) failed NCLEX-RN 1,437 1,332 (92.69) 105 (7.31) 2,484 2,223 (89.49) 261 (10.51) 3,921 Note. The NCLEX-RN pass rate was significantly higher for students who attended that used the HESI case studies than for students who attended that did not use the HESI case studies, χ 2 (1, N = 3,921) = 10.64, P.001. NCLEX-RN outcomes were not available for 462 of the total sample of 4,383. participating students, 1,597 (36.44%) attended that used the case studies, and 2,786 (63.56%) attended that did not use the case studies (see Table 1). The mean E 2 score of the 1,597 students who used the case studies was , and the mean E 2 score of the 2,786 students who did not use the case studies was A t test analysis indicated that the students who used the case studies had significantly higher E 2 scores than the students who did not use the case studies, t(3,229) = 4.58, P.000, (see Table 2). Of the 4,383 participating students, NCLEX-RN outcomes were unavailable for 462 students because they did not graduate, their NCLEX-RN outcomes were unavailable to their deans or directors, or the deans or directors declined to provide the data. Therefore, the total student sample used for analysis regarding NCLEX-RN outcomes consisted of 3,921 students: 1,437 (36.65%) who used the case studies and 2,484 (63.35%) who did not use the case studies. Of the 1,437 students who used the case studies, 1,332 (92.69%) passed the NCLEX-RN on their first attempt, and 105 (7.31%) failed. Of the 2,484 students who did not use the case studies, 2,223 (89.49%) passed the NCLEX-RN on their first attempt, and 261 (10.51%) failed. Because NCLEX-RN outcomes are reported as pass/fail, which are nominal-level data, a chi-square was used to analyze the data. Findings indicated that significantly more students who used the case studies Table 2. Comparison of Mean E 2 Scores for Students Who Attended Schools That Used HESI Case Studies and Students Who Attended Schools That Did Not Use HESI Case Studies HESI case study use n Mean E 2 score SD t P Confidence interval 95% Lower Upper Students attending that used the case studies 1, Students attending that did not use the case studies 2, Total students 4,383 Note. Mean E 2 scores were significantly higher (P.000) for students who attended that used HESI case studies than for students who attended that did not use HESI case studies.

4 S20 YOUNG ET AL Table 4. HESI Case Study Implementation Methods Described by Schools of Nursing That Used the HESI Case Studies Method of Percent of Remediation Exam preparation Course grade Clinical preparation Postclinical conference Total 24 More than one method may have been implemented by individual. passed the NCLEX-RN on their first attempt than students who did not use the case studies, χ 2 (1, N = 3,921) = 10.64, P.001, (see Table 3). Deans and directors of the 24 that reported using the case studies answered three questions on the S7 Participant School Survey regarding methods used to implement the case studies within their school of nursing. Based on data obtained from responses to these questions, the primary uses for the case studies were remediation and exam preparation. Of the 24 that used the case studies, 18 (75.00%) deans or directors described using the case studies for remediation, and 15 (62.50%) described using the case studies for exam preparation. The case studies were used as part of the course grade by 8 (33.33%) of the, for clinical preparation by 6 (25.00%) of the, and for postclinical conferences by 5 (20.83%) of the (see Table 4). Summary, Discussion, and Recommendations This study was based on data obtained for S7, which investigated the predictive accuracy of the E 2 by soliciting information from the deans or directors of the participating regarding students' NCLEX-RN outcomes. Data regarding ' use of the Elsevier online case studies were reported by the deans or directors that responded to the S7 Participant School Survey. Mean E 2 scores and NCLEX-RN pass rates of students who used the case studies and those who did not use the case studies were compared. Both E 2 scores and NCLEX-RN pass rates were significantly higher for students who used the case studies. It is likely that E 2 scores and students' first-time NCLEX-RN success rate were higher for those who used the case studies because the case studies focus on application of content and require the use of critical thinking skills to answer the questions provided with each case study. The online case studies therefore provide students with valuable practice in using their nursing knowledge and critical thinking skills to solve clinical problems. However, the percentage of students at each school who completed the case studies and the percentage of case studies each student completed could not be determined. In reviewing the findings of this study, one must consider that the mean scores could have been influenced by intervening variables. For example, it is possible that the faculty at that used the case studies worked more closely with students in helping them remediate than did the faculty at that did not use the case studies, which might explain why they purchased the case study license in the first place to help students remediate. Such faculty assistance might explain why students who used the case studies had higher E 2 scores and a higher NCLEX-RN pass rate than students who did not use the case studies. Additionally, the quality of the student population at each school could have differed, thereby influencing the findings of this study. Future studies regarding the usefulness of case studies should investigate the E 2 scores and NCLEX-RN outcomes of individual students, and researchers should also consider stratifying the sample by the number of the case studies each student completed, rather than simply looking at those who attended that reported using the case studies. As it was in this study, all identifying student information should be expunged prior to providing the data to the researchers so that the participants' confidentiality is protected. This was a preliminary study that investigated methods used to implement case studies and, as such, provided descriptive data only. Future studies should obtain a larger sample size of that use the case studies and compare case study implementation methods in terms of E 2 scores and NCLEX-RN outcomes, thereby scientifically investigating the value of various methods used to implement case studies within of nursing. Conclusions Seven previously published studies indicate that the E 2 is highly accurate in predicting NCLEX-RN success, and the findings of this study provide nursing students and nursing faculty with direction in terms of preparing for the E 2 and ultimately for the NCLEX-RN. Deans and directors reported that Elsevier's online case studies were most often used for remediation and exam preparation. It seems that the case studies were helpful with remediation and exam preparation because both the mean E 2 score and the NCLEX-RN pass rate were significantly higher for students who used the case studies than for students who did not use the case studies. It would therefore seem judicious for deans and directors to consider using the Elsevier online case studies to assist students in preparing for the E 2 and ultimately for the licensing exam. References Adamson, C., & Britt, R. (2009). Repeat testing with the HESI Exit Exam Sixth validity study. CIN: Computers, Informatics, Nursing, 27, Beers, G. W. (2005). The effect of teaching method on objective test scores: Problem-based learning versus lecture. Journal of Nursing Education, 44, Costa, M. L., van Rensburg, L., & Rushton, N. (2007). Does teaching style matter? A randomized trial of group discussion

5 ONLINE CASE STUDIES S21 versus lectures in orthopaedic undergraduate teaching. Medical Education, 41, Delpier, T. (2006). Cases 101: Learning to teach with cases. Nursing Education Perspectives, 27, Dowd, S. B., & Davidhizar, R. (1999). Using case studies to teach clinical problem-solving. Nurse Educator, 24, Kim, S., Phillips, W. R., Pinsky, L., Brock, D., Phillips, K., & Keary, J. (2006). A conceptual framework for developing teaching cases: A review and synthesis of the literature across disciplines. Medical Education, 40, Lauchner, K., Newman, M., & Britt, R. (1999). Predicting licensure success with a computerized comprehensive nursing exam: The HESI Exit Exam. Computers in Nursing, 17, Lauver, L. S., West, M. M., Campbell, T. B., Herrold, J., & Wood, G. C. (2009). Toward evidence-based teaching: Evaluating the effectiveness of two teaching strategies in an associate degree nursing program. Teaching and Learning in Nursing, 4, Lewis, C. (2005). Predictive accuracy of the HESI Exit Exam on NCLEX-RN pass rates and effects of progression policies on nursing student Exit Exam scores. Dissertation Abstracts International, 66, 154B (UMI No ). Mihal, C. (2006). The impact of HESI case studies on the HESI Exit Examination scores for nursing students preparing for the National Council Licensure Examination for Registered Nurses. Unpublished doctoral dissertation, Seton Hall University, South Orange, New Jersey. Morrison, S., Adamson, C., Nibert, A., & Hsia, S. (2004). HESI exams: An overview of reliability and validity. CIN: Computers, Informatics, Nursing, 22, Morrison, S., Nibert, A., & Flick, J. (2006). Critical thinking and test item writing (2nd ed.). Houston, TX: Health Education Systems, Inc. Newman, M., Britt, R., & Lauchner, K. (2000). Predictive accuracy of the HESI Exit Exam: A follow-up study. Computers in Nursing, 18, Nibert, A., & Young, A. (2001). A third study on predicting NCLEX success with the HESI Exit Exam. Computers in Nursing, 19, Nibert, A., Young, A., & Adamson, C. (2002). Predicting NCLEX success with the HESI Exit Exam: Fourth annual validity study. CIN: Computers, Informatics, Nursing, 20, Young, A., & Willson, P. (2012). Predicting NCLEX-RN success: The seventh validity study of the HESI Exit Exam. CIN: Computers, Informatics, Nursing, 30,

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