By Susan Sportsman, PhD, RN, ANEF, FAAN
COVID-19 has changed how nurse educators prepare students for practice. The changes in the health care environment—and nursing specifically—over the last decade have given faculty numerous challenges: integration of important new content in an already “stuffed” curriculum, evolving expectations of students, parents and college administrators, and the difficulty in finding appropriate clinical sites and sufficient numbers of faculty. As if these challenges weren’t enough, now faculty must cope with an international pandemic that has huge implications personally and professionally. In addition to their other responsibilities, faculty now must prepare students for practice using masks, social distancing, and limited clinical sites-all while working from home!
One thing, however, has not changed. Nurse educators must prepare students for safe practice in this very complicated world. The measurement of a student’s ability to practice safely is based upon his or her success on the NCLEX Examination. Similarly, the measure of quality for each nursing program is based upon the annual NCLEX first-time pass rate.
Despite this focus on the first-time pass rate of the NCLEX as a measure of success of the program, questions remain as to whether first-time NCLEX pass rates are a valid measure of a program’s success. The nursing literature highlights the issue of whether first-time NCLEX pass rates, when used alone, are valid measures of the quality in nursing programs (Giddens, 2009; Taylor, et.al, 2014). The National Council of State Boards of Nursing (NCSBN) recognized this concern and raised the question, “Are there other evidence-based metrics that individually or together might amend or replace the current regulatory standards in each state?” (Spector et al, 2020).
In 2017, the NCSBN began a three-year research agenda to answer this question. The research study was published in the Nursing Journal of Regulation in July, 2020. Because much of the work of Collaborative Momentum Consulting involves helping faculty evaluate and improve their curricula, program, and student success on NCLEX, I was excited to read the results of this study. I was very impressed with this robust and well-considered research and I highly recommend that each of you read the publication. To pique your interest, let me give you a small dose of the results.
The study, titled NCSBN Regulatory Guidelines and Evidence-Based Quality Indicators for Nursing Education Programs, has three components. First, researchers implemented a comprehensive literature review to determine if NCLEX pass rates are effective as a measure of performance of pre-licensure nursing program quality. This literature search sought to answer the question, “Is there evidence that identifies quality indicators of nursing programs and warning signs that might indicate the program is in trouble?” (Spector, 2020). Next, a Delphi study, using the findings from the literature review, resulted in consensus by experts regarding nursing program quality indicators and areas of concern. Finally, the researchers analyzed 15 years of most of the US Boards of Nursing annual reports and 5 years of site visit documents (2,853 documents) from 40 US Boards of Nursing from 2012 to 2017 (Spector, et al, 2020). This analysis served to confirm findings from the literature review and the Delphi study.
Some of the findings which caught my interest include:
In addition to providing a basis for the Delphi study, the review also elicited evidence of elements integral to a quality clinical experience, including opportunities for:
- clinical decision-making and reasoning
- effective delegation
- electronic data and information management
- emergency procedures
- interprofessional communication
- pharmacology knowledge
- time management and prioritization
- understanding pathophysiology
The literature also indicated that failing to address unsafe students in the clinical area could be a warning sign for a nursing program.
The two rounds of the Delphi study found consensus among educators, regulators, and clinical nurses who supervised new graduates, regarding potential quality indicators and warning signs of nursing programs in trouble. These include:
- Evidence-based curriculum that emphasizes:
- quality and safety standards for patients
- critical thinking and clinical reasoning skills
- Role-modeling of professional behaviors by faculty
- Clinical experiences with actual patients that prepare students for the reality of clinical practice
- Systematic process in place to address and remediate student practice errors
- Current clinical competence of faculty teaching clinical courses
- Consistent administrative leadership in the nursing program
- Collaboration between education and practice to enhance readiness for practice
- Ongoing systematic evaluation of the nursing program
- Institutional administrative support of the nursing program
- Consistent patterns of NCLEX pass rates that meet set standards
- Administrative support for ongoing faculty development
- Significant opportunities for students in a variety of clinical experiences with diverse populations
- Consistent full-time faculty, as opposed to reliance on adjunct faculty
- Quality simulation used to augment clinical experience
- Comprehensive student support services
- National nursing accreditation
- Admission criteria that emphasize a background in the sciences
- Evidence-based curriculum that emphasizes:
- Lack of consistent and prepared clinical faculty
- Limited clinical experiences that do not prepare students for practice
- Poor leadership in the nursing program
- Inconsistent or decreasing trend of NCLEX pass rates
- Complaints about nursing program to Boards of Nursing from employers, students, or faculty
- Pattern of nursing administration and faculty attrition
- Unwillingness of health care institutions to host clinical experiences for the nursing programs students
Although the results of the Delphi study regarding quality indicators, warning signs, and outcomes were identified by experts and were consistent with findings in the literature review, the report noted that opinions of experts are the lowest level of evidence.
Analysis of Annual Reports and Site Visit Data
The results of this analysis identified several emerging themes. Unsurprisingly, the main signal for a site visit by the Board of Nursing in any state was NCLEX pass rates of ≤ 80% for four or more quarters. Student complaints and/or public formal complaints were also an indicator, and these complaints seemed to trigger a more detailed assessment than site visits due to low NCLEX pass rates.
Other warning signs include:
- The lack of administrative and operational procedures, policies, and resources to ensure adequate recordkeeping for students and faculty, support faculty productivity, and facilitate program leadership
- Programs that fail to use data to set admission, progression, and student performance standards, particularly if these are persistent over time. This difficulty may be exacerbated by lack of competence in interpreting and using data to set standards and the lack of internal statistical support to conduct predictive analysis
- Student and/or faculty concerns regarding a lack of recent clinical practice experience among faculty
- High faculty turnover, lack of success in recruiting faculty, poor faculty compensation
- Lack of teaching and learning resources
- Diminished leadership of the nursing program, including giving nursing leadership additional responsibilities, the lack of education of the director, and the concern when the leader is not a nurse
- Lack of support from student affairs support, administrative support, libraries and information technology, resources to support clinical learning experiences such as finding and monitoring clinical sites, simulation and laboratory supplies.
Certainly, this review covers only the highlight of this important study. I highly recommended that faculty read this article and use the results to evaluate your pre-licensure program. This study validates in many ways what we all believed were quality measures and warning signs for nursing programs. The study also holds some surprising findings, which will help nursing programs be more adept at continuous improvement in their programs. Here is the reference:
Spector, N., Silvestre, J., Alexander, M., Martin, B, Hooper, J., Squires, A., Ojemeni, M. (2020) NCSBN regulatory guidelines and evidence-based quality indicators for nursing education programs. Journal of Nursing Regulation. July. 11(2) S1-S64. https://www.journalofnursingregulation.com/article/S2155-8256(20)30075-2/fulltext.
Thank you to the NCSBN leadership for this excellent research study. I know that I will use these findings to inform my consulting practice in nursing education and I hope all of you will integrate it into your own practices as well.
Giddens, J. (2009) Changing Paradigms and Challenging Assumptions: Redefining Quality and NCLEX Pass Rates. Journal of Nursing Education, 48. 123-124.
Spector, N., Silvestre, J., Alexander, M., Martin, B, Hooper, J., Squires, A., Ojemeni, M. (2020) NCSBN regulatory guidelines and evidence-based quality indicators for nursing education programs. Journal of Nursing Regulation. July. 11(2) S1-S64. https://www.journalofnursingregulation.com/article/S2155-8256(20)30075-2/fulltext. Accessed, August, 2020.
Taylor, H., Loftin, C., Reyes, H. (2014) First-time NCLEX-RN pass rates: Measurement of program quality or something else. Journal of Nursing Education. 53(6). 336-341.