FORECASTING NURSING STUDENT SUCCESS AND FAILURE ON THE NCLEX-RN USING PREDICTOR TESTS. Lawrence A. Santiago. Copyright 2013

Transcription

1 FORECASTING NURSING STUDENT SUCCESS AND FAILURE ON THE NCLEX-RN USING PREDICTOR TESTS by Lawrence A. Santiago Copyright 2013 A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Education University of Phoenix

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3 ABSTRACT A severe and worsening nursing shortage exists in the United States. Increasing numbers of new graduate nurses are necessary to meet this demand. To address the concerns of increased nursing demand, leaders of nursing schools must ensure larger numbers of nursing students graduate. Prior to practicing as registered nurses in the United States, graduates of nursing schools must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Various companies, such as the Assessment Technologies Institute (ATI) and Kaplan have created NCLEX-RN predictor tests that report candidates chances of passing the NCLEX-RN. ATI created a test called the RN Comprehensive Predictor and Kaplan created an NCLEX-RN predictor examination called the Kaplan Readiness Test. Students with less than optimal scores on the predictor can remediate to improve their knowledge of nursing, critical thinking, and test-taking skills. The intent for the ATI RN Comprehensive Predictor and the Kaplan Readiness Test is to predict the probability of success on the NCLEX-RN. The focus of the quantitative study was the ability of the aforementioned examinations to predict both success and failure on the NCLEX-RN. The overall TEAS score did not have a significant relationship with NCLEX-RN results. However, the ATI TEAS Math score was significantly higher (p =.005) for students who passed the NCLEX-RN. Data analysis showed no significant relationship between the Kaplan NCLEX-RN Readiness Test and NCLEX-RN results (p >.05). A significant relationship between the ATI RN Comprehensive Predictor and the NCLEX-RN scores existed in both the total sample (p =.001) and the BSN subsample (p =.001). In the MSN student subsample, all 37 students passed the NCLEX on the first attempt. iii

4 DEDICATION This work is dedicated to my parents, Mildred and Larry. Thank you for helping me become who I am today.

5 ACKNOWLEDGMENTS I would like to take this opportunity to thank all of the individuals who have supported me in this doctoral program. First of all, I would like to thank God for all of the blessings He has given me in this life. Through the past four years, my family s love, support, and encouragement has sustained me through this journey. My wife Myla has been by my side through each course, each residency, and each stage of the dissertation process. Asawa, mahal na mahal kita! A special thanks to my son Joshua. You are the best son a father could have. I would also like to thank my dissertation committee. Dr. Phan, thank you for your continued inspiration throughout the dissertation process. Dr. Tidwell, thank you for sharing your expertise and experience with me. Finally, Dr. McAtee, thanks for being so reliable over the years. I would also like to thank the nursing department, including Dr. Susan Drummond, Dr. Geneva Oaks, Jeanette Russell, and Lynne Bosch. Thanks for helping with my study and answering my many s. Finally, I would like to thank my colleagues for their steadfast support: Millicent De Jesus, Caroline Alfonso, Jeffrey Woods, and Karen Silva. Thanks for always being there for me! I cannot forget the support of my director, Peachy Hain. You have truly been my cheerleader through this process. ii

6 TABLE OF CONTENTS Contents Page List of Tables... vi Chapter 1: Introduction...1 Problem Statement...2 Purpose of the Study...6 Significance of the Problem...7 Significance of the Study...7 Nature of the Study...9 Research Questions...11 Hypotheses...12 Theoretical Framework...13 Definition of Terms...14 Assumptions...15 Scope, Limitations, and Delimitations...16 Summary...17 Chapter 2: Review of the Literature...19 Title Searches, Articles, Research Documents, and Journals...20 Bloom s Taxonomy and Revision...20 Nursing Shortage...22 Societal Need...25 History of Nursing Licensure Examinations...26 NCLEX-RN...26 iii

7 Quality of Nursing Programs...27 Predictive Validity...28 High-Stakes Testing...29 Test Anxiety...31 Computerized Testing...31 Costs of NCLEX-RN Failure...32 Historical NCLEX Predictor Research...32 Current NCLEX Predictor Research...33 Beyond the NCLEX-RN...40 Attitudinal Change...41 Gaps in the Literature...41 Summary...42 Chapter 3: Research Methods...44 Research Method and Design Appropriateness...44 Population...45 Sampling...45 Geographic Location...46 Data Collection...46 Instrumentation...47 Validity and Reliability...48 Data Analysis...49 Research variables...49 Logistic regression analysis...49 iv

8 Summary...49 Chapter 4: Results...51 Research Questions...51 Data Analysis...52 Testing of the Hypotheses...54 Findings...57 Testing of the Hypotheses...58 Chapter Summary...60 Chapter 5: Conclusions and Recommendations...61 Purpose of the Study...61 Research Questions...62 Summary of Key Findings...63 Implications...64 Limitations...65 Suggestions for Future Research...66 Significance...67 Practitioner Recommendations...68 Conclusion...69 References...71 Appendix A: Data Collection Tool...83 Appendix B: Permission to Use Premises Form...84 Appendix C: Letter of Collaboration Among Institutions...85 v

9 LIST OF TABLES Table 1: Frequency Counts for Selected Demographic Variables (N = 251)...53 Table 2: Descriptive Statistics for Selected Variables (N = 251)...53 Table 3: Distribution of Predicted and Actual NCLEX Scores and Pass Rates for 2007 Predictor (n = 162)...54 Table 4: Distribution of Predicted and Actual NCLEX Scores and Pass Rates for 2010 Predictor (n = 57)...55 Table 5: t Test Comparisons Based on NCLEX Outcome for Selected Variables 56 Table 6: Relationship Between Outcome of ATI Screening Test and NCLEX Outcome...58 vi

10 Chapter 1 Introduction A severe and worsening nursing shortage exists in the United States (American Association of Colleges of Nursing [AACN], 2011) and more new-graduate nurses are necessary to meet this demand. To address the concerns of increased nursing demand, larger numbers of nursing students must graduate from nursing schools (Roa, Shipman, Hooten, & Carter, 2011). Prior to practicing as registered nurses in the United States, graduates of nursing schools must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is the national registered nurse licensing examination (National Council of State Boards of Nursing [NCSBN], 2011). Various companies such as the Assessment Technologies Institute (ATI) and Kaplan have created NCLEX-RN predictor tests that report a candidate s chances of passing the NCLEX-RN (ATI, 2012; Kaplan, n.d.). Leaders at ATI created a test called the RN Comprehensive Predictor (ATI, 2012) and leaders at Kaplan created an NCLEX- RN predictor examination called the Kaplan Readiness Test (Kaplan, n.d.). Students with less than optimal scores on the predictor can remediate to improve their knowledge of nursing, critical thinking, and test-taking skills. The intent for the ATI RN Comprehensive Predictor and the Kaplan Readiness Test is to predict the probability of success on the NCLEX-RN. The focus of the current quantitative study is the ability of the aforementioned examinations to predict both success and failure on the NCLEX-RN. Leaders at ATI also created the Test of Essential Academic Skills (TEAS). Educators at various schools of nursing use this test as part of the admissions requirements. Students at these schools, including the school in the current study, must 1

11 achieve a certain score on the test, determined by each school, to be eligible for admission to their school of nursing (ATI, 2011). The purpose of the test is to ensure admitted students are more likely to be successful in nursing school and to pass the NCLEX-RN than those students who scored below the indicated passing mark on the TEAS. The focus of the current quantitative study was also on the ability of the TEAS to predict success and failure on the NCLEX-RN. Chapter 1 contains the problem and purpose of the quantitative, retrospective study. The study focus was on the ability of the TEAS, the ATI RN Comprehensive Predictor, and the Kaplan Readiness Test to forecast the outcome of NCLEX-RN results for the total population of registered nurse candidates from a school of nursing in California. Due to reasons unknown to the researcher, only 219 of the 251 graduates took the ATI RN Comprehensive Predictor, and only 100 of the 251 graduates took the Kaplan NCLEX-RN Readiness Test. Literature on NCLEX-RN predictor accuracy of nursing board examination failure is lacking. Therefore, determining the accuracy of these standardized tests to predict success and failure might assist in establishing the degree of usefulness for prospective registered nurses. Research such as this quantitative study could lead to earlier NCLEX-RN success and alleviation of the nursing shortage. When nursing students pass the NCLEX-RN earlier, they will be able to obtain employment and lessen the nursing shortage. Problem Statement A gap exists in the literature regarding the ability of the ATI RN Comprehensive Predictor or the Kaplan NCLEX-RN Readiness Test to forecast failure on the NCLEX- RN accurately. Twenty percent of nursing schools in the United States will not allow 2

12 students to graduate and receive their nursing degree unless they pass the predictor test (National League for Nursing [NLN], 2012). A review of the EBSCOhost and ProQuest databases revealed no studies on the predictive accuracy of the Kaplan NCLEX-RN Readiness Test. EBSCOhost and ProQuest are use-for-fee research database providers that allow students and researchers to view articles from thousands of peer-reviewed journals (EBSCO Industries, 2012; ProQuest, 2012). The quantitative, retrospective study involved examining the ATI TEAS scores, the ATI RN Comprehensive Predictor scores, and the Kaplan Readiness Test scores for the total population of graduates from a nursing school in California. The purpose of the study was to determine the extent to which these standardized tests can accurately predict both passing and failure on the NCLEX-RN. Background of the Problem The nationwide nursing shortage continues to worsen. As baby boomers age, the need for nurses to care for this population will increase (AACN, 2011). The U.S. Census Bureau (2006) defined baby boomers as Americans born between 1946 and Baby boomers include Americans born in foreign countries who immigrated to the United States (U.S. Census Bureau, 2006). As of 2006, the U.S. Census Bureau reported that 77,980,296 baby boomers resided in the United States. The nursing shortage is even worse in California because the state has mandatory nurse-to-patient ratios (Aiken et al., 2010). These ratios include five patients per nurse in a medical/surgical acute setting and two patients per nurse in an intensive/critical care setting (California Department of Public Health, 2010). Nurses in California care for one less patient on average than other states (California Department of Public Health, 2010). Because of this mandatory ratio, it 3

13 is more difficult to staff hospitals in California with sufficient numbers of nurses than in other states (California Department of Public Health, 2010). California is the only state in the United States with mandatory nurse ratios (American Nurses Association, 2011). Insufficient staffing decreases patient safety, increases work-related stress and injuries for nurses, and causes nurses to leave the profession (AACN, 2011). Large numbers of registered nurses will retire over the next 25 years, contributing to a projected shortage of 265,000 nurses by 2025 (Buerhaus, Staiger, & Auerbach, 2009). The demand for registered nurses will continue to increase, which will create the largest shortage of nurses since the 1960s (Buerhaus et al., 2009). The average life expectancy in the United States is 77.8 years, and the United States will experience a substantial increase in its elderly population over the next 30 years, from now until 2033 (Orman & Guarneri, 2009). By 2030, all baby boomers will be over 65 years old (Buerhaus et al., 2009). Increasing the number of prospective registered nurses who can successfully pass the NCLEX-RN will assist in alleviating the nursing shortage. The NCLEX-RN passing standard has increased in recent years, which could potentially place more graduate students at risk for failure (Carrick, 2011). Although nursing school leaders in California should always ensure their graduating students are ready to pass the NCLEX-RN and join the nursing workforce, the worsening shortage further indicates the importance of first-time NCLEX-RN success (AACN, 2011). The purpose of an NCLEX-RN predictor test is to identify readiness for students to sit for the exam and areas of weakness to assist with remediation. A significant number of nursing schools in the United States use NCLEX-RN predictor tests to determine whether students can receive approval to take the NCLEX- 4

14 RN (Spurlock & Hunt, 2008). The primarily reason for designing exit examinations is to predict readiness for the NCLEX-RN. Many schools use the exit exam as a high-stakes test. Nichols and Berliner (2008) defined high-stakes testing as the practice of attaching important consequences to high stakes test scores (p. 41). High-stakes nursing tests require students to pass before they can obtain approval to take the NCLEX-RN (Harding, 2010). If nursing instructors are failing students based on the results of a highstakes test, then the test must accurately predict failure on the NCLEX-RN (Giddens, 2009; Spurlock & Hanks, 2004). A limited number of NCLEX-RN predictor studies have shown prediction of failure rates to be less than 50% accurate (Benefiel, 2011; Spurlock & Hanks, 2004). Potentially, some students held back would pass the NCLEX- RN with the first attempt. Students capable of passing the NCLEX-RN should be able to sit for the test, pass the national board examination, and begin their careers as registered nurses (Spurlock & Hanks, 2004). Nursing leaders should identify variables that affect NCLEX-RN pass rates (Ukpabi, 2008). An NCLEX-RN predictor test can help students to determine the knowledge and concepts that were deficient in their ability to pass the NCLEX-RN (Ukpabi, 2008). For the ATI RN Comprehensive Predictor, nursing instructors have the option to provide students with a breakdown of the specific topics for which the students require remediation (ATI, 2011). Remediation should be the primary purpose of a predictor examination, not being a singular measure of progression in a nursing program (Ukpabi, 2008). 5

15 Purpose of the Study The purpose of the quantitative study was to determine if the TEAS, the ATI RN Comprehensive Predictor, and the Kaplan NCLEX-RN Readiness Test could accurately predict both success and failure on the NCLEX-RN at one nursing program in Southern California. The quantitative study took place at one nursing program in the Southern California region. This program offers both a baccalaureate degree program (bachelor of science in nursing, BSN) and an accelerated entry level master s degree program (master of science in nursing, MSN). If these tests can accurately predict student outcomes on the NCLEX-RN, they will be valuable tools for selecting students for remediation (Uyehara, Magnussen, Itano, & Zhang, 2007). Faculty can identify students at risk for failing the NCLEX-RN and develop an individualized tutoring and mentoring program for them (Uyehara et al., 2007). The interventions are one method of increasing the nursing school s first-time NCLEX-RN pass rate (Uyehara et al., 2007). The quantitative study involved a statistical analysis that measured the ability of the students ATI TEAS results, their ATI RN Comprehensive Predictor results, and their Kaplan Readiness Test results to predict both success and failure on the NCLEX-RN. The school required students to take all three examinations. Due to reasons unknown to the researcher, only 219 of the 251 graduates took the ATI RN Comprehensive Predictor. In addition, only 100 of the 251 graduates took the Kaplan NCLEX-RN Readiness Test. Because the purpose of the study was to determine the extent to which the predictor tests can individually forecast success on the NCLEX-RN, a quantitative, retrospective study design was appropriate. Because the study involved comparing the NCLEX-RN result to the NCLEX-RN predictor result, a retrospective design was necessary. 6

16 Significance of the Problem Although employment of registered nurses is increasing rapidly, the growth might not be enough to meet the increasing demand (Bureau of Labor Statistics, 2012). In 2011, leaders at the AACN reported 135,000 registered nurse vacancies. Of all registered nurse positions in the United States, 8.1% were vacant. This is an alarming statistic because the nursing shortage persists in a time of economic recession (AACN, 2011). As nurses retire, the number of newer nurses entering the profession is not sufficient to meet the demand (Buerhaus et al., 2009). Nursing schools must ensure they graduate every student who is able to safety practice as a registered nurse. The number of elderly will dramatically increase because the baby boomer generation is aging (Buerhaus et al., 2009). More nurses will be necessary to care for the older population (Bureau of Labor Statistics, 2009). If nursing school prorgression policies prevent a large number of nursing students capable of passing the NCLEX-RN from graduating, this group of prospective nurses is a delayed resource because these individuals will not be able to assist in alleviating the nursing shortage in a timely manner. More research on NCLEX-RN predictor failure accuracy is necessary because of the insufficient number of studies on this topic. In addition, a review of the literature revealed published studies on the Kaplan NCLEX-RN Readiness Test, which opened an opportunity for further research to validate this test. Significance of the Study The quantitative study involved comparing student results of the TEAS test, the ATI RN Comprehensive Predictor, and the Kaplan Readiness Test to their result on the NCLEX-RN. The findings might assist nursing leaders with developing policies for 7

17 remediation. Although other researchers have measured the accuracy of exit exams to predict passing the NCLEX-RN, few researchers have sought to measure the accuracy of these exams to predict failure (Abbott, 2008; Adamson & Britt, 2009; Landry, Davis, Alameida, Prive, & Renwanz-Boyle, 2010). Prediction to pass relates to the result of the predictor test. If the predictor test result is 60%, the prediction is that the student will have a 60% chance of passing the NCLEX-RN and a 40% chance of failing the NCLEX- RN (ATI, 2011; Kaplan, n.d.). A lack of literature exists on the topic of NCLEX-RN predictor failure. Also, a review of literature did not reveal any studies measuring the predictive accuracy of the Kaplan NCLEX-RN Readiness Test. The predictor tests provide scores after students complete the examinations. A table is provided for faculty that attaches the scores to percentages that indicate the chances of passing the NCLEX-RN if the students were to take it that day. If a highstakes test cannot accurately predict failure on the NCLEX-RN, passing such a test should not be a requirement for graduation from the nursing program (Harding, Rateau, & Heise, 2011). The primary purpose of the proposed study is to examine the ability of the ATI RN Precdictor Test and the Kaplan NCLEX-RN Readiness Test to determine failure on the NCLEX, as well as passing. Although it is important for educators to determine if students are ready for the NCLEX-RN examination, it is critical to choose a valid research design to confirm these predictions. This research design includes the ability of the research instruments to predict NCLEX-RN success as well as failure. Through careful scrutiny of research design, researchers can implement an accurate study (Burns & Grove, 2009). Using the appropriate research design will further validate the findings of the study and increase the 8

18 ability of the results to apply to other academic settings. The next section will provide a brief overview of the chosen research design for the study. Nature of the Study The quantitative, retrospective study involved examining the predictive accuracy of the ATI TEAS test scores, the ATI RN Comprehensive Predictor scores, and the Kaplan Readiness Test scores to forecast both passing and failing the NCLEX-RN at one school of nursing in Southern California. Retrospective studies are nonexperimental, and no manipulation of the subjects occurs (Burns & Grove, 2009). In a retrospective study, a researcher attempts to link an event to another event that occurred prior to the first one (Burns & Grove, 2009). The current study involved linking NCLEX-RN results to NCLEX-RN predictor tests taken before the students graduation. A multiple regression analysis served to determine if a relationship exists between the test scores and the NCLEX-RN outcomes. The software used to perform the analysis was Statistical Package for the Social Sciences (SPSS) 21. A retrospective, quantitative design was the ideal method to compare standardized test data to the NCLEX-RN. Retrospective studies involve measuring current circumstances that might have a relationship with past circumstances (Polit & Beck, 2008). The current study involved analyzing NCLEX-RN scores with ATI TEAS scores, ATI RN Comprehensive Predictor scores, and Kaplan Readiness Test scores to determine the extent of their relationship. Qualitative research designs were not appropriate for the study. A Southern California baccalaureate degree nursing program was the site for the retrospective study. Data collection consisted of examining archived data. The data 9

19 included ATI TEAS scores, ATI RN Comprehensive Predictor scores, and Kaplan NCLEX-RN Readiness Test scores. Prospective nursing students take the TEAS before admission to nursing school and take the exit tests during the last semester of the nursing program. The researcher collected the data on the campus. He received archived student test results and he recorded the results onto the Data Collection Tool (see Appendix A). Archived data analysis is cost-effective, accessible, and available (Creswell, 2005). Data collection proceeded in an organized, systematic manner that maximized the generalization of the findings (LoBiondo-Wood & Haber, 2008). The data gathered were from one nursing program in Southern California after receiving approval from the school s institutional review board (IRB) as well as the IRB from University of Phoenix. All applicants to the nursing school must take the TEAS to receive consideration for admission to the nursing school. All students take both the ATI RN Comprehensive Predictor and the Kaplan Readiness Test prior to graduation. Due to reasons unknown to the researcher, only 219 of the 251 graduates took the ATI RN Comprehensive Predictor. In addition, only 100 of the 251 graduates took the Kaplan NCLEX-RN Readiness Test. The study involved measuring only the first attempt of these predictor examinations. Students who fail one or both of these examinations must enter a remediation course. After the course, the student will retake the test. Students must pass this examination to graduate. The study involved comparing results data from five student cohorts ( ) to the students pass fail data on the NCLEX-RN. Student consent was not a requirement because the study involved analyzing existing data sets. No personal contact with any nursing students or graduates took place. Data collection occurred during a review of retrospective files at the school of nursing. The 10

20 use of codes rather than student names served to protect students identity. The researcher consistently matched all scores with the correct code number. Research Questions The research project included two questions. The questions were appropriate to the study and highlighted the dependent and independent variables. The study involved determining the extent to which three standardized nursing exams could predict both success and failure on the NCLEX-RN at one nursing school in Southern California. 1. How are ATI RN Comprehensive Predictor and Kaplan Readiness Test examination scores (independent variable) related to results on the NCLEX-RN (dependent variable)? Recent studies have shown the ability of NCLEX-RN predictor examinations to forecast success on the NCLEX-RN accurately (Harding et al., 2011; McGahee, 2010; Ukpabi, 2008). The predictor tests examined included the Health Education Systems, Inc. (HESI) Exit Exam, the ATI RN Comprehensive Predictor test, and the Educational Resources Inc. (ERI) test. The ERI test was an NCLEX-RN predictor test that no longer exists (Bondmass, Moonie, & Kowalski, 2008). Lacking in the literature were studies on the ability of NCLEX-RN predictor exams to forecast failure on the NCLEX-RN accurately. The current study involved analyzing both success and failure predictions. A multiple regression analysis assisted with the study (LoBiondo-Wood & Haber, 2008). In some schools of nursing, including the school in the current study, students must pass an NCLEX-RN predictor examination prior to graduation and prior to receiving permission to sit for the nursing board examination. If the predictor test cannot accurately forecast failure on the NCLEX-RN, the progression policy might not be fair to the students. The 11

21 focus of the second research question was NCLEX-RN failure and NCLEX-RN predictor accuracy. 2. How are nursing school admissions test scores (independent variable) related to results on the NCLEX-RN (dependent variable)? Researchers recently examined the relationship between high scores on standardized nursing school admissions examinations and positive results on the NCLEX-RN, but a gap exists in the literature regarding the relationship between low scores on the admissions exams and negative results on the NCLEX-RN. The two research questions served as guides during data collection. The focus of the study was the results of the ATI TEAS test, the ATI RN Comprehensive Predictor test, and the Kaplan Readiness Test compared with the NCLEX-RN results. A statistical analysis assisted in determining the answers to the study questions. Hypotheses Parallel to the research questions were the following null and alternative hypotheses: H1 0 : The ATI RN Comprehensive Predictor test score is not significantly related to results on the NCLEX-RN. H1 a : The ATI RN Comprehensive Predictor test score is significantly related to results on the NCLEX-RN. H2 0 : The Kaplan Readiness Test score is not significantly related to results on the NCLEX-RN. H2 a : The Kaplan Readiness Test score is significantly related to results on the NCLEX-RN. 12

22 H3 0 : The ATI TEAS nursing school admissions test score is not significantly related to results on the NCLEX-RN. H3 a : The ATI TEAS nursing school admissions test score is significantly related to results on the NCLEX-RN. The study determined the extent to which the ATI TEAS test, the ATI RN Comprehensive Predictor, and the Kaplan Readiness Test could foretell both success and failure on the NCLEX-RN. The preceding hypotheses were appropriate for the quantitative, retrospective nature of the study. Theoretical Framework For both nursing schools and the NCSBN, one of the primary educational goals is for students to develop didactic and clinical competency. Bloom s taxonomy has historically served as a guide for faculty to determine what is the appropriate level at which a nursing student must function. Bloom, Engelhart, Furst, Hill, and Krathwohl (1956) first developed the taxonomy to classify learning outcomes. Nursing faculty typically focus on the cognitive domain of Bloom s taxonomy because this framework is the basis of the formulation for the NCLEX-RN test plan (NCSBN, 2011). NCLEX-RN predictor test plans must be congruent with Bloom s taxonomy or they risk a decrease in compatibility with the NCLEX-RN. Although the original 1956 publication of Bloom s taxonomy was not research based, the 1999 revision was evidence based. Research conducted after the 2001 publication further validated the concepts. Nasstrom (2009) conducted a study in which the findings indicated Bloom s revised taxonomy is an acceptable tool for understanding mathematical concepts. Bumen (2007) conducted a study that involved comparing the 13

23 initial 1956 taxonomy to the revision. Bumen found the revised taxonomy was superior to the initial taxonomy when applied to lesson planning skills. Bloom s taxonomy is an excellent guide for teaching students about the nursing process (Duan, 2006). This is particularly true for the taxonomy s cognitive domain. Nursing faculty often use these concepts to develop nursing program and course objectives. The levels of the taxonomy such as knowledge and comprehension are appropriate for beginning nursing students, and instructors gradually integrate the higher concepts such as application and analysis into instruction (Duan, 2006). For test questions, instructors should be aware to which cognitive level the question relates. Test developers must weave the elements of the taxonomy into NCLEX-RN predictor test plans, as the pattern of the actual NCLEX-RN aligns with Bloom s taxonomy. Definition of Terms Some of the terminology in the study was specific to undergraduate nursing education. Such terms are not common knowledge to society. This section includes a discussion of the terms. Bachelor of science in nursing (BSN) program: A BSN program is a 4-year higher education program that prepares students to become licensed registered nurses (Chitty & Black, 2011). Graduates are eligible to sit for the NCLEX-RN. The sample in the current quantitative study included graduates from a BSN program. ATI RN Comprehensive Predictor: Students typically take this test toward the end of the nursing program (ATI, 2011). This examination is computerized and has 180 items. Test developers at ATI developed this examination. The quantitative study included the ATI RN Comprehensive Predictor as a predictor variable. 14

24 National Council Licensure Examination for Registered Nurses (NCLEX- RN): The NCLEX-RN is a computer adaptive test (NCSBN, 2011). The computer-based examination assesses for minimum competency levels for candidates seeking to become registered nurses in the United States. Test developers at the NCSBN strive to create a test that will ensure safe nursing practice. California Board of Registered Nursing (BRN): The California Board of Registered Nursing (BRN, 2011) is the government organization that approves and monitors nursing programs in the state of California. Test of Essential Academic Skills (TEAS): The TEAS is a standardized examination typically given either prior to admission to nursing school or at the beginning of a nursing program (ATI, 2011). The examination has 170 questions, including 55 English and language use items, 30 science items, 45 mathematics items, and 40 reading items. Assumptions Assumptions are present in all research studies (Neuman, 2003). Identifying the assumptions in a study will assist the researcher to better comprehend the various concepts in the study (Neuman, 2003). Several assumptions existed in the proposed quantitative study. The first assumption was that the data collection would be accurate. The rationale for this assumption included the researcher following protocol for retrospective data collection. The second assumption was the execution of the data analysis would be correct. The rationale for this assumption included the researcher performing an accurate data analysis. The third assumption was that the administration of the ATI TEAS test, the ATI RN Comprehensive Predictor, and the Kaplan Readiness 15

25 Test would be appropriate to the nursing students. The fourth assumption was that the nursing students in the study would follow the same or a similar curriculum during nursing school. Assumptions about the research design also existed. One assumption was no unknown or unacknowledged variables influenced the study. An example of this was the assumption that all students from the nursing program studied had fully met the admission criteria required by the institution. Another assumption was the admission criteria from the nursing program were similar to other programs in the state of California. Scope, Limitations, and Delimitations The scope of the study included graduate nurses from a prelicensure nursing program in Southern California. The population included program graduates from the past 10 cohorts. These include seven cohorts from the traditional baccalaureate program and three cohorts from the entry level master s program. The data collected were the archived results of the students TEAS test, ATI RN Comprehensive Predictor, Kaplan Readiness Test, and NCLEX-RN. Data collected were from the graduating cohorts between 2006 and Although NCLEX-RN scores exist, the study involved collecting only pass fail data. The dependent variable was the outcome of the NCLEX- RN. The sample was a limitation because the nursing students all came from the same school. The program was relatively new as it began in 2006; therefore, the data gathered were from 10 graduating cohorts of students. Also, the sample was a convenience sample. A convenience sample is a group of individuals chosen at the discretion of the 16

26 researcher (Burns & Grove, 2009) and does not involve an attempt to capture an accurate representation of the population. Selecting the sample did not involve randomization, which is the assignment of study participants by chance, rather than at the discretion of the researcher (Burns & Grove, 2009). The scores of students with previous health care careers remained part of the sample. The data collected were for the total population of graduated cohorts. Delimitations are the defined boundaries of a study (Burns & Grove, 2009). The data collection tool used in the study was one such delimitation. The geographical location of the study was also a delimitation (Burns & Grove, 2009). The study took place at one baccalaureate nursing school in Southern California. Summary The nursing shortage in the United States is severe and worsening. By 2020, the national shortage could increase to more than 1 million full-time equivalent registered nurses (Health Resources and Services Administration, 2010). NCLEX-RN predictor examinations forecast both success and failure on the board examination. Some nursing schools mandate that students pass predictor examinations to progress or graduate. If the predictor test is not accurate, then it should be a determination of competence for nursing students. The purpose of the quantitative retrospective study was to compare the results of NCLEX-RN predictor tests to actual NCLEX-RN results on 10 cohorts of undergraduate nursing students at a Southern California university. The dependent variable was the NCLEX-RN results. The independent variables were the predictor test results. 17

27 Chapter 2 will include a literature review on NCLEX predictor research. Also included will be discussion on the study s chosen theoretical framework, Bloom s taxonomy. The chapter also contains a discussion on the history of nursing shortages in the United States, as well as the current nursing shortage. 18

28 Chapter 2 Review of the Literature The purpose of the retrospective, quantitative study was to determine the extent to which the ATI TEAS test, the ATI RN Comprehensive Predictor, and the Kaplan Readiness Test could accurately forecast both success and failure on the NCLEX-RN. The proposed study included one baccalaureate degree and entry-level master s degree nursing program in Southern California. A program requirement is that students achieve a set passing score on the TEAS prior to admission to the program. Students must also pass both the ATI RN Comprehensive Predictor and the Kaplan Readiness Test to graduate and take the NCLEX-RN. A high first-time student pass rate on the NCLEX-RN is crucial to validate a successful nursing program (BRN, 2011). The BRN (2011) mandates that schools maintain at least a 75% first-time pass rate. Approximately one third of nursing schools in the United States use NCLEX-RN predictor tests to determine whether students can graduate from their programs (NLN, 2012). Exit examinations, including the ATI RN Comprehensive Predictor and the Kaplan Readiness Test, primarily predict readiness for the NCLEX-RN and do not predict failure on the test (Spurlock & Hunt, 2008). Many schools use the exit exam as a high-stakes test. High-stakes tests such as NCLEX-RN predictor examinations require students to pass before they can receive approval to take the NCLEX-RN (Spurlock & Hunt, 2008). The focus of this chapter is a review of peer-reviewed publications in which researchers have addressed the nursing shortage and NCLEX predictor examinations. The literature review consists of six sections. The first section includes a review of 19

29 nursing shortages throughout the history of the United States and the societal need for nurses. The second section includes a discussion on the history of nursing licensure examinations in the United States. The third section contains a description of the concept of predictive validity and recent studies that include a measure of the predictive validity of an examination. The fourth section will contain a review of historic and recent research from peer-reviewed publications pertaining to NCLEX predictor tests. The fifth section will include a discussion of gaps in the literature. The sixth section will consist of a discussion on leadership. Title Searches, Articles, Research Documents, and Journals An electronic literature search using EBSCOhost provided articles published after The search included the following keywords: NCLEX, HESI, ATI, Kaplan, nursing, student, shortage, and Bloom s taxonomy. The search yielded 70 referenced articles and documents. Of the total references in the study, the dates for 85% were after Bloom s Taxonomy and Revision One of the chief directives of the NCSBN is for nursing students to develop didactic and clinical competency (NCSBN, 2011). Since the 1950s, Bloom s taxonomy has functioned as a tool for nursing faculty to establish the appropriate cognitive level to which a student must perform. Bloom, Englehart, Furst, Hill, and Krathwohl (1956) initially developed the taxonomy to categorize learning outcomes. Nursing faculty typically focus on the cognitive domain of Bloom s taxonomy because the NCLEX-RN test plan is formulated on this framework (NCSBN, 2011). To maximize the predictive 20

30 ability of an NCLEX-RN predictor test, Bloom s taxonomy is necessary to assist in formulating its test plan. In 1999, Anderson and Krathwohl (2001) revised the taxonomy to include the following levels: remember, understand, apply, analyze, evaluate, and create. In the cognitive domain, three of the six levels changed. The levels are no longer hierarchical in nature (Ari, 2011). Nursing faculty expect that students will gradually master each level, beginning with remembering (Duan, 2006). Remembering involves the ability to recall knowledge from memory, such as with anatomical sites and names of medications. The next level is understanding, wherein the learner can interpret meaning from information. If a patient has chest pain, the student with understanding can state that the patient possibly had a heart attack. Applying is the next level. A nursing student who masters this level can successfully write a care plan. If a patient complains of constipation, the student can assess for signs and symptoms of constipation, diagnose the patient, set a goal to restore normal bowel function, and implement interventions to relieve constipation. Analyzing is the next level. A student is able to separate a concept into individual parts and learn how the parts relate to each other. A student is also able to determine the overall purpose of these parts. Evaluation is the next level, wherein a student is able to make decisions and determine if the intervention is effective or ineffective. The final level is creating. A student is able to put the pieces together and create a logical structure, discuss a patient s plan with care with the patient s family, perform discharge planning, and produce discharge teaching instructions for the patient. The NCSBN (2011) reported, NCLEX-RN and NCLEX-PN examinations may include items written at various cognitive levels. The majority of items are written at the 21

31 application or higher levels of cognitive ability (p. 11). This section includes a discussion on both the 1956 work by Bloom and the 1999 update. Because Bloom s taxonomy is the basis of the NCLEX-RN test plan, nurse educators should also consider lining up Bloom s instructional theory with their own curriculum (Duan, 2006). NCLEX-RN predictor test developers must also base their test plan and test items on Bloom s taxonomy. Writing instructional outcomes using the keywords from Bloom s taxonomy, such as analyze and evaluate, will help students understand the level of competency at which they must function to meet the objectives of the particular course (Boland, 2009). This practice will create a congruency between the nursing school s curriculum and the NCLEX-RN test plan. Using Bloom s taxonomy will also increase similarity between NCLEX-RN predictor tests and the actual NCLEX-RN. In addition to the six cognitive levels of Bloom s taxonomy, the 1999 update includes another four kinds of knowledge. The additions were factual, conceptual, procedural, and metacognitive elements (Anderson & Krathwohl, 2001). The elements allow instructors to engage students in activities that, while maintaining focus on the cognitive domain, include affective and psychomotor aspects. Using this array of elements in instruction will prepare students for the NCLEX-RN and for becoming safe, effective, and caring nurses. In the clinical area, instructors must determine at what cognitive level the student is functioning. Senior nursing students should demonstrate evidence of thinking at the analysis, application, and evaluation levels (Duan, 2006). Nursing Shortage Several nursing shortages have occurred since the post-world War II era (1945- present). In 1947, the Hill-Burton Act became law (Buerhaus, 1987). The law allowed a 22

32 large increase in the number of hospitals in the United States. The Hill-Burton Act greatly increased the demand for nurses (Buerhaus, 1987) and significantly influenced the modern health care system, especially regarding in-hospital patient care. The U.S. government has taken various steps to alleviate the nursing shortages throughout history. In 1964, President Johnson signed the Nurse Training Act into law (Yett, 1975). The law enabled nurses to receive hospital-managed loans by which nursing students would receive funding for school. The nurses would pay back the loans interest-free over 10 years after completing nursing school, as long as they worked fulltime as a registered nurse. The intent for the law was to entice potential nursing students to enter school who otherwise would not be able to afford nursing school. Buerhaus (1991) analyzed hospital wage increases during times of nursing shortage compared to times of adequate staffing. The intent for the increases was to entice licensed nurses who were not working. Hospitals offered wage increases during times of shortage. Hospitals that could not afford such wage increases hired lower cost employees, such as licensed practical nurses and nurses aides. The current nursing shortage began in 2000 (Chitty & Black, 2011). Several factors make the current shortage unique compared to previous crises. There are 77 million baby boomers compared to 44 million people in the next generation following, known commonly as Generation X (Americans born between 1965 and 1985; AACN, 2011). Increasing health care resources will be necessary for baby boomers as they age. Typically, as a person ages, they will require more health care needs, including hospitalizations (Buerhaus et al., 2009). In 2006, there were 37 million people over 65 in 23

33 the United States (Federal Interagency Forum on Aging Related Statistics, 2009). This number will more than double by the year Another unique issue of the current nursing shortage is that the number of nursing schools in the United States is inadequate to supply the health care system with the number of nurses needed (Buerhaus et al., 2009). For the school year, 36,511 qualified students applied for admission to nursing programs in California, and the programs did not accept 61.7% of the applicants (BRN, 2011). The statistics clearly indicated the number of applicants far exceeded the seats available. The situation is disturbing, considering the high demand for nurses in health care (Buerhaus et al., 2009). Increasing numbers of nurses are leaving the profession compared to the past. The stress and intensity of the work causes many nurses to leave their jobs (Chitty & Black, 2011). Nurses also experience a number of physical ailments rendering them unable to work, including back, knee, and wrist injuries (Chitty & Black, 2011). Technological advances have also caused some nurses to leave their jobs because they do not feel comfortable adjusting to changes such as computerized documentation (Chitty & Black, 2011). Technologies include computerized documentation, electronic medication storage, and barcode medication administration. Rapid advances are challenging for some older nurses (Chitty & Black, 2011). Several solutions to alleviate the current nursing shortage exist. One such solution was the implementation of nurse patient ratios to reduce work-related stress and improve patient care (Tevington, 2011). The nurse patient ratio had the opposite effect to some degree, as a decreased nurse patient ratio requires more nurses for each hospital unit (Tevington, 2011). Another solution for nursing shortages has been for hospitals to 24

34 recruit nurses from foreign countries, although the cost of recruiting foreign nurses is high and the result is not always positive (Ross, Polsky, & Sochalski, 2005). Societal Need The largest contributing factor to the nursing shortage over the next 20 years will be the baby boomer population in the United States (AACN, 2011). As this population ages, it will become a large obligation for the American health care system that will require a greater number of registered nurses in the health care workforce. Schools of nursing must ensure they will graduate the largest number of qualified students possible (Giddens, 2009). In addition to aging patients, registered nurses are also aging. In 2007, the average age of registered nurses in the United States was 43.7 years old (AACN, 2011). By the year 2025, many nurses from the baby boomer generation will retire. These nurses need replacing by greater numbers of nurses from succeeding generations. By 2025, the United States might experience a nursing shortage of 260,000 nurses, which is double the number of nurses needed in 2007 (AACN, 2011). Adequate nursing staffing is essential to patient safety. Kane, Shamliyan, Mueller, Duval, and Wilt (2007) performed a meta-analysis of 28 studies that focused on the relationship between registered nurse staffing and patient deaths and complications. Kane et al. found when registered nurses are present on patient units, length of stay on intensive care units and postsurgical units was significantly less. To address the concerns of increased nursing demand and an aging workforce, nursing schools must have larger numbers of nursing students graduate (Roa et al., 2011). Nursing programs should not have attrition policies that fail potentially capable students. 25

35 Through increased support, counseling, guidance, and remediation, nursing faculty can guide greater numbers of nursing students to graduate nursing school and pass the NCLEX-RN the first time (Uyehara et al., 2007). History of Nursing Licensure Examinations Before 1944, every state had its own nursing licensure examination (Matassarin- Jacobs, 1989). Beginning in 1944, nursing graduates sat for the State Board Test Pool Examination developed by the NLN. During this time, each state maintained its own pass rate, but this become problematic when nurses moved from one state to another (Birnbach, 1982). By 1978, the NCSBN began to oversee the State Board Test Pool Examination, redesigned the test to include criterion referencing, and set a standardized passing score at The NCSBN renamed the examination to the NCLEX-RN. In 1988, the examination changed to a pass fail format (Matassarin-Jacobs, 1989). NCLEX-RN To work as a registered nurse in the United States, each nursing school graduate must pass the NCLEX-RN (NCSBN, 2011). The intent for the NCLEX-RN was to ensure nurses in the United States can practice safe patient care (NCSBN, 2011). The examination initially began as a paper and pencil examination. Since 1994, the NCLEX- RN has been a computerized adaptive test, which is a test that adapts to the ability level of the examinee (NCSBN, 2011). Every 3 years, the NCSBN reexamines the rigor of the NCLEX-RN. Since 1994, the NCSBN has modified the NCLEX-RN four times, based on a practice analysis survey. Aucoin and Treas (2005) studied the practice analysis survey, as the results of the survey lead to modifications on the NCLEX-RN Test Plan. The survey has a return 26