Teaching and Learning in Nursing 13 (2018) 18–26 Contents lists available at ScienceDirect Teaching and Learning in Nursing journal homepage: www.jtln.org Strategies to Improve NCLEX-RN Success: A Review Brenna L. Quinn, PhD, RN, NCSN ⁎, Megan Smolinski, Anya Bostain Peters, PhD, RN, CNE University of Massachusetts Lowell, School of Nursing, Lowell, MA 01854, USA a r t i c l e Keywords: Nursing education NCLEX-RN Exit examinations Test-taking skills Critical thinking i n f o a b s t r a c t Successful completion of the National Council Licensure Examination for Registered Nurses (NCLEX-RN) is important to both new graduate nurses and schools of nursing (SONs); therefore, it is crucial for nursing faculty to prepare students to pass this examination. This article reports results of a literature review aiming to identify effective approaches to strengthen NCLEX-RN success for prelicensure nursing students. SONs have worked to improve student critical thinking, test-taking skills, and psychosocial well-being. SON should consider multifaceted approaches to help students find success on the NCLEX-RN. © 2017 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. Introduction The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the final step before becoming an independently practicing nurse. The NCLEX-RN is a computerized examination that ensures that graduate nurses possess basic competencies (Smith, 2002) required to practice safely as a registered nurse (RN). The examination requires utilization of critical thinking and problem solving to answer questions related to caring for patients across the lifespan. As patient care complexity has increased, the threshold for basic competency has also increased. As a result, the examination has become more difficult to pass, with an 84.57% pass rate in 2016 compared with 90.34% in 2012 for first time test takers educated in the United States (National Council of State Boards of Nursing, 2013, 2017). NCLEX-RN failure affects test takers' confidence, sense of identity, and hope of becoming an RN (Poorman & Webb, 2000). Failure can lead to feelings of embarrassment, social stigma, grief, and anxiety and guilt over disappointing family members and employers (Claudette, 2014; Roa, Shipman, Hooten, & Carter, 2011). Failure also delays nursing graduates from realizing income at the level of an RN (Smith & Crawford, 2002). In addition to impacting the test taker, NCLEX-RN failure can have negative effects on nursing programs. The first time pass rate is reflective of a nursing program's success and is used by state boards of nursing and accrediting agencies to assess the program's success (Taylor, Loftin, & Reyes, 2014). For The research did not receive any specific grant from agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. Tel.:+ 1 781 727 9343. E-mail address: Brenna_Quinn@uml.edu (B.L. Quinn). student success and programmatic reasons, it is crucial for schools of nursing (SONs) to adequately prepare students for the NCLEX-RN. NCLEX-RN preparation varies among nursing programs, but it is vital to ensure that all students enrolled in nursing programs are prepared using evidence-based strategies. Currently, many programs are implementing standardized examinations in order to expose students to the format of the examination and identify either students at risk for first time NCLEX-RN failure or those who are unlikely to find success on the examination (Nibert, Young, & Britt, 2006). Some schools have implemented progression policies based on the ability of these standardized examinations to predict NCLEX-RN success. Despite the utility of these examinations, graduate nurses failing the NCLEX-RN examination on the first attempt attribute failure to lack of knowledge in preparation, study techniques, and test-taking strategies (Griffiths, Papastrat, Czekanski, & Hagan, 2004). Further, students and faculty have identified test-taking anxiety as prohibitive to success on the NCLEX-RN (Alizadeh et al., 2014; Gibson, 2014; Røykenes, Smith, & Larsen, 2014). Although there are several interventions faculty can implement to reduce anxiety, such as modifying student behavior or the examination environment, these interventions can be costly and time consuming (Quinn & Peters, 2017). Given the variety of preparation techniques, a review of strategies to facilitate NCLEX-RN success is needed. Purpose SONs and students enrolled have a vested interest in graduate nurses passing the NCLEX-RN on the first attempt. Nursing faculty may struggle to identify what constitutes adequate preparation for the examination or what strategies are most helpful to facilitating https://doi.org/10.1016/j.teln.2017.09.002 1557-3087/© 2017 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 success. The purpose of this article is to identify effective approaches to strengthen NCLEX-RN success for prelicensure nursing students. Methods Search Procedure The Preferred Reporting Items for Systematic Reviews and MetaAnalysis guidelines directed the literature search (Moher, Liberati, Tetzlaff, & Altman, 2009). The terms NCLEX and success were searched in the electronic database Cumulative Index to Nursing and Allied Health Literature. All sources were accessed through a university library. Sources illustrating successful NCLEX-RN preparation strategies for students were of interest for this review. Articles meeting the following inclusion criteria were included: available in the English language, published in peer-reviewed scholarly journals, and published between 2006 and 2016. Original research articles and discussion papers were included if they presented results related to student success or NCLEX-RN pass rate changes. If the article was a literature review or did not describe an intervention, the source was excluded. A nurse as first author limiter was applied. Data Extraction and Analysis A summative approach to content analysis was used during data extraction and analysis (Hsieh & Shannon, 2005). Article characteristics (e.g., publication year, sample size) and variables of interest (e.g., NCLEX-RN success interventions, sample sizes, results) were extracted and organized in a data matrix. Results A total of 243 nonduplicate sources were identified through database search. Following a review of the title and abstract, 214 articles were excluded, as they did not contain data relevant to NCLEX-RN success interventions. Of the remaining 29 articles, 11 were excluded following full-text review as these articles were literature reviews or as relevant results were not presented (e.g., outcomes of NCLEX-RN success interventions). Eighteen articles were included for review. The source-selection process is displayed in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis diagram (Fig. 1). All 18 articles were published in nursing journals. The majority of the researchers sampled baccalaureate nursing students. Table 1 displays manuscript characteristics for the 18 included publications and samples as described by manuscript authors. Summary of Evidence Following data analysis of the 18 included sources, five types of interventions implemented to improve NCLEX-RN success emerged. These interventions included exit examinations (n = 13 articles addressing), success strategies (n = 11), curriculum change (n = 6), progression policies (n = 8), and faculty training (n = 1). Table 2 displays data from each reviewed source. Summaries of included articles are presented below. Faculty at one SON changed approaches to assessment testing, test-taking strategies, student self-assessment, review courses, and review books to improve NCLEX-RN success (Bonis, Taft, & Wendler, 2007). Assessment tests, an independent study module regarding NCLEX-RN tips and practice questions, and a simulated National Council Licensure Examination (NCLEX) were required during senior year. Over a 3-year time period, the NCLEX-RN pass rate improved from 84% to 95% (p b .01). Graduates were invited to share NCLEXRN results and factors influencing success or failure on the NCLEX- 19 RN on a Web-based survey. Students responding to the survey stated, despite implemented changes, that they felt unprepared to answer NCLEX-RN questions related to prioritization and delegation. Respondents noted practice questions, practice tests, a test review plan, and review materials as most helpful to success on the NCLEX-RN. Stress management techniques varied but did appear helpful to success. A retrospective correlational study to compare the accuracy of the two computerized exit examinations was performed (Brodersen & Mills, 2014). A total of 317 prelicensure nursing students' exit test results, personal demographics, educational demographics (American College Testing [ACT] score, cumulative grade point average [GPA]), and NCLEX-RN blueprint (to compare changes in the passing standard) were compared with NCLEX-RN success or failure. Of the 317 participants, 93.1% passed the NCLEX-RN. Students who did not pass had significantly (p b .01) lower ACT scores, cumulative GPAs, and scores on both computerized exit examinations. Although the researchers determined that the two exit examinations could predict NCLEX-RN passing (specificity for both = 99), the examinations were not predictive of failure (sensitivity = 18.2 and 13.6, respectively). Graduates of one SON reported financial hardships and limited time to study for the NCLEX-RN and, therefore, waited 4 to 6 months following graduation to test (Carr, 2011). This SON's 5-year mean performance was 73.2%, prompting changes throughout the school. The SON implemented weekly comprehensive NCLEX-RN-style examinations. Students were required to show improvement on weekly examination scores, complete an online review course, and apply for the NCLEX-RN. Faculty members were also subjects in this study, as they participated in a workshop to learn how to teach test-taking strategies and completed an online NCLEX-RN review course to understand student experiences. Following the interventions, faculty incorporated more NCLEX-RN-style questions. The SON implemented standardized examinations and required passing scores. The NCLEX-RN pass rates improved over a 5-year period from 83% to 100%. Researchers noted a positive change in student attitudes as the NCLEX-RN success rates climbed; students expressed wanting to maintain success rates of the school. Davenport (2007) reported a proactive approach to increasing NCLEX-RN success in one associate's degree nursing program. The approach included content-specific computerized examinations, a required number of practice NCLEX-RN items, and test-taking strategy seminars for students. Emphasis was placed on these interventions being program long, beginning in the first semester and continuing with advising, resources, review courses, and study plans in the final semester. The SON also offered a comprehensive assessment and remediation package offered by a national testing company that allowed students to take computerized NCLEX-RN-style examinations and receive feedback on individual and group performance. The validity of this standardized examination is unclear as up to 13% of students passing the NCLEX-RN on the first attempt scored low on the examinations. Researchers noted difficulty in identifying at-risk students, as the SON did not require a benchmark score for the standardized examination. Revision of an NCLEX-RN review course, required in the senior year, was undertaken at one SON (Cox-Davenport & Phelan, 2015). First, students were required to participate in weekly adaptive quizzes and reach a benchmark score. There was a significant positive correlation between score and number of questions answered, number of quizzes, and number of log-ins. The researchers also determined that students passing the NCLEX-RN answered an average of 1,282.33 (SD = 373.98) questions compared with an average of 2018.50 (SD = 672.46) for those students failing the NCLEX-RN (statistically significant at the p b .01 level). Students who answered more questions did not necessarily achieve a higher score; students may have been answering more questions only to reach a certain 20 B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 PRISMA Flow Diagram Fig. 1. PRISMA flow diagram. Illustrates the article search and selection process using PRISMA. score, where higher performing students required fewer questions before achieving the score indicative of NCLEX-RN readiness. Students were required to complete a review course following graduation if at least one of three NCLEX-RN predictor examinations was not passed. Following the course revision, predictor examination pass rates decreased, whereas NCLEX-RN pass rates increased to 97%. Farley Serembus (2016) implemented a comprehensive improvement plan following decreases in end-of-program comprehensive standardized examinations and first time NCLEX-RN pass rates. Strategies included requiring a 2.75 science GPA prior to admission and increasing the percentage of NCLEX-RN-style testing in courses to 90%. In addition, the school changed progression policies. Students were required to earn a grade of C or better in clinical courses, could only fail one nursing course, and were not permitted to attempt pharmacology more than two times. Students not meeting these standards were dismissed from the program. After 1 year, the NCLEX-RN pass rate increased from 73% to 96% and remained in the 90% range for 3 subsequent years. One SON experienced an unexpected drop in first time NCLEX-RN pass rates to 73% (Frith, Sewell, & Clark, 2008). There was no Table 1 Manuscript Characteristics First author, year Journal Sample Sample size Bonis et al., 2007 Brodersen & Mills, 2014 Carr, 2011 Davenport, 2007 Cox-Davenport & Phelan, 2015 Farley Serembus, 2016 Frith et al., 2008 Giddens & Morton, 2010 Homard, 2013 Jacobs & Koehn, 2006 March & Ambrose, 2010 McDowell, 2008 Norton et al., 2006 Poorman et al., 2010 Schooley & Kuhn, 2013 Sifford & McDaniel, 2007 Spalla et al., 2007 Yeom, 2013 Nursing Education Perspectives CIN: Computers, Informatics, Nursing Nursing Education Perspectives Nursing Education Perspectives CIN: Computers, Informatics, Nursing Journal of Nursing Regulation CIN: Computers, Informatics, Nursing Nursing Education Perspectives Journal of Nursing Education Journal of Professional Nursing Nursing Education Perspectives Journal of Nursing Education Journal of Professional Nursing Nurse Educator Journal of Nursing Education Nursing Education Perspectives Nurse Educator Nurse Education Today Sophomore, junior, and senior baccalaureate students Baccalaureate students Baccalaureate cohorts Associate degree students Senior nursing students Baccalaureate and diploma program students Senior nursing students Baccalaureate students Senior nursing students Baccalaureate students Baccalaureate students Baccalaureate cohorts Baccalaureate students Senior nursing cohorts Associate degree students Senior nursing students Senior nursing students Baccalaureate students 315 317 5 300 69 a Size not specified. a 60 189 269 a 31 6 186 2 306 47 a 151 B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 21 Table 2 Themes and Evidence First author, Themes year addressed Bonis et al., 2007 Brodersen & Mills, 2014 Evidence Exit • Exit examinations required during the first semester of senior year examinations • Simulated NCLEX-RN during final 6 weeks of senior year Success strategies Exit examinations • Independent study module test-taking tips and practice questions required during second semester of senior year • Administration of standardized examinations 2 weeks in to final semester to identify areas needing improvement before administration of the standardized exit examination Results • NCLEX-RN pass rate improved from 84.09 to 94.81 (p b .01) • Students report via a survey practice questions, practice tests, review plan, and review materials most helpful to NCLEX-RN success • Students who did not pass the NCLEX-RN were 6.9%; these students had significantly lower (p b .01) ACT scores, cumulative GPAs, and standardized examination scores • No statistically significant differences in gender, race, or NCLEX-RN blueprint for students passing and failing the NCLEX-RN • Standardized exit examinations predictive of NCLEX-RN pass (specificity for both = 99) and not predictive of failure (sensitivity = 18.2 and 13.6, respectively) • Following a 5-year NCLEX-RN pass rate mean performance of 73.2%, the pass rates for the 5 years following the changes were 83%, 93%, and 95% and 2 years of 100% • NCLEX review course altered to require students to pass comprehensive examinations with 55% for the first 3 weeks, 65% for middle 6 weeks, and 72% for last 3 weeks of semester. • Applying for NCLEX-RN mandatory course requirement, completed during class time Curriculum • Standardized examinations administered online. Evaluation tool change created to aid in the development of course syllabi Progression • Passing score for online standardized examinations higher than the policies suggested minimum Faculty • Faculty participated in a teaching workshop related to test-taking training strategies. Faculty completed online an NCLEX-RN review course to understand student requirements Davenport, Exit • Standardized comprehensive examinations were implemented; a • Thirteen percent of students passing the NCLEX-RN on the first 2007 examinations benchmark score was not required attempt scored below recommended levels on the comprehensive standardized examination Success • Success plan starting in the first semester, including required strategies NCLEX-RN practice items and test-taking strategy seminars Success • Students were required to take weekly adaptive quizzes and reach • NCLEX-RN pass rate increased to 97%; however, performance on Coxa mastery level of 4.3 the comprehensive predictor examinations decreased Davenport strategies • Removal of need to pass one of three comprehensive examinations; • Passing of one, two, or three predictor examinations did not show & Phelan, Progression policies students failing all three examinations could graduate but were statistically significant differences in adaptive quizzing mastery level 2015 required to participate in an NCLEX-RN review course prior to • The average mastery level on adaptive quizzes was 5.17 (SD = graduation 0.89) • There was a positive correlation between mastery level and number of questions answered, number of quizzes, and number of log-ins • Students who passed the NCLEX-RN answered an average of 1,282 adaptive quizzing questions, whereas those failing answered 2,018 questions. • The passing group had a mastery level average of 5.18, whereas the failing group had an average of 5.05 Curriculum • Percentage of objective, NCLEX-style testing in course grades • After 1 year, the NCLEX-RN pass rate rose from 73% to 96% and Farley increased from 40 to 60% to 90% remained in the 90% range for 3 additional years Serembus, change Progression • Admission GPA of 2.75 required 2016 policies • Clinical course passing grade increased to a C • Students permitted to fail either one nursing course or pharmacology twice; additional failures resulted in dismissal from the nursing program Frith et al., Exit • Implementation of standardized specialty examinations at the start • Standardized exit examination pass rate improved from 30% to 89%, 2008 examinations of each semester and upon program exit and the NCLEX-RN pass rate improved from 83% to 90% over 3 years Success • Test-taking strategies and psychological support offered in an strategies NCLEX-RN preparation course • Students scoring 950 or higher on standardized exit examination asked to tutor low-scoring students • Students scoring high on Sarason's Test Anxiety Scale were referred to university counseling services Curriculum • Development of an NCLEX-RN preparation course change • A passing score of 850 was required for the standardized exit examination Progression • Students scoring below 850 were required to meet with policies faculty to create a study plan and meet with a mentor for 4 weeks before retaking the standardized exit examination Exit • Standardized examinations administered 6 months prior to • Surveys and focus groups of students and faculty revealed Giddens & examinations graduation to identify at-risk students noticeable and positive differences in graduates' work as registered Morton, nurses 2010 Curriculum • Program change from two 16-week semesters with an 8-week • Immediately following the curriculum changes, NCLEX-RN pass change summer term to three 14-week terms rates dropped from 90% to 83% but returned to 89% after 2 years • Implementation of concept-based education • Program offered to students in rural sites via interactive video conferencing Carr, 2011 Success strategies (continued on next page) 22 B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 Table 2 (continued) First author, Themes year addressed Evidence Results • Mean Exit Examination 1 score for the first, second, and third cohorts of students were 725, 803, and 818, respectively • Mean Exit Examination 2 scores for the first, second, and third cohorts of students were 778, 815, and 869, respectively • NCLEX-RN pass rates for the first, second, and third cohorts were 73%, 59%, and 86%, respectively. Of note, the second cohort's mean GPA was 3.17, whereas mean GPAs for Cohorts 1 and 3 were 3.37 and 3.33 Exit • Eleven standardized examinations implemented over four • NCLEX-RN pass rates rose from 86% to 92% Jacobs & examinations semesters of nursing school • Thirteen percent of students scored below the national Koehn, Progression • Remediation required for students not achieving a 60% or better on standardized percentile, 50% of these students failed the NCLEX-RN 2006 policies the standardized examinations Exit • Computerized exit examination with 160 items required in senior • Following an 83% NCLEX-RN pass rate; following changes, pass March & rates increased to 95% over the course of 5 years Ambrose, examinations year Success • Students not achieving score of 850 or better on exit examination 2010 strategies required to partake in remediation and retake examination at own expense • Students failing to achieve an 850 on the second attempt required to meet with faculty member • All students required to develop study plan for NCLEX-RN based on exit examination performance reports Curriculum • Nursing leadership course content changed to include leadership change and management theories, delegation, cultural diversity, managed care, nurses as change agents, quality improvement McDowell, Exit • Comprehensive NCLEX-RN required • NCLEX-RN pass rates rose from 77% to 100% in 5 years 2008 examinations Success • Students required to create individual study plan for the NCLEX-RN strategies based on performance reports from computerized examinations • Students mentored in anxiety control, including positive attitudes and vision of a goal, imagery and meditation use, healthy eating, sleeping, diversional activities, study habits, completing practice examinations on a computer, and visiting the NCLEX-RN test site prior to testing • Students were advised to schedule NCLEX-RN preparation as if it were an appointment, to complete 50 NCLEX-style questions in 1 hr or 100 questions in 2 hr, and to complete a total of 2,000–4,000 practice questions depending on students' risk level Norton et al., Exit • Standardized comprehensive examinations implemented in the • Seventy-one percent of students passed the NCLEX-RN with the 2006 examinations final semester minimal number of questions • The university experienced a significant increase in the percentage of students passing the NCLEX-RN on the first try (percentages not published) Success • Students required to apply for the NCLEX-RN in a capstone course strategies • Students required to complete 11 online examinations composed of over 800 NCLEX-style questions • Three-day NCLEX preparation course held on campus; school reimbursed students 50% of course cost if they passed the NCLEX within 90 days of course completion Curriculum • A one-credit course was developed and required for academically change at-risk students (determined by scholastic aptitude test scores, exit examination scores, science and nursing course grades, clinical performance, learning disabilities, and test anxiety) • Of note, all students were invited to enroll in a course Progression • Students were required to achieve a grade of C or better in all policies nursing and science courses • Students were permitted to retake science courses as many times as needed to achieve a grade of C but could only retake nursing courses one time prior to program dismissal • Students were required to score 65% or better on exit examination and were permitted to take examination up to three times • Students were only allowed to complete the second semester of a senior practicum if they achieved 65% on the exit examination Poorman et al., Success • Three-credit course for second-semester senior students at risk for • Students enrolled in the course had a 92% NCLEX-RN pass rate, whereas the pass rate of the entire cohort was 85% 2010 strategies failing the NCLEX-RN (determined by scoring below the 30th • The following year, students enrolled in the course had a 100% pass percentile on the exit examination) developed rate, whereas the entire cohort had a 95% pass rate • Cognitive behavior techniques, metacognitive strategies, and NCLEX-RN practice questions implemented in the course • Standardized specialty and exit examinations implemented • Fundamental standardized examination was determined to be the Schooley & Exit examinations most statistically significant predictor of NCLEX-RN success, followed Kuhn, by the maternity standardized examination 2013 • Performance in pediatric, maternity, and medical–surgical nursing courses was predictive of standardized examinations in these courses. Homard, 2013 Exit • Implementation of standardized specialty and exit examinations examinations • One cohort of students did not use standardized examinations; a second cohort used pharmacology and fundamentals standardized examinations, whereas a third cohort used standardized examinations for pharmacology, fundamentals, maternity– pediatrics, and medical–surgical • All students took an exit examination prior to graduation B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 23 Table 2 (continued) First author, Themes year addressed Evidence Results Exit • Exit examination implemented for junior-level students Sifford & McDaniel, examinations • Students achieving a score lower than 850 were required to take the examination again during the first semester of senior year 2007 • Performance in anatomy and physiology courses was statistically significant to standardized examination performance • Performance in a senior capstone class was statistically significant to standardized exit examination performance • Exit examination means improved from 735 to 810 after remediation course participation; however, only 38% of students participating in remediation achieved an exit examination score of 850 • Students achieving a score of less than 850 required to take a 15week remediation course focused on NCLEX-style practice questions, test-taking strategies, and anxiety management Success • Faculty members created an “NCLEX Review Question of the Day” • The program encouraged students to take ownership of their strategies e-mailed to senior students NCLEX-RN preparation and encouraged faculty–student communication Exit • Standardized specialty examinations were implemented • No statistically significant difference was found between examinations throughout the nursing curriculum fundamentals and pediatric examinations for students passing or failing the NCLEX-RN • Statistically significant differences in scores on medical–surgical, pharmacology, maternal–newborn, mental health, community health, leadership, and management for students passing and failing the NCLEX-RN • Only medical–surgical, pharmacology, and community health standardized examination performance predictive of NCLEX-RN success and failure Success strategies Spalla et al., 2007 Yeom, 2013 statistically significant difference in GPA or in scores on an exit examination between those who passed and those who failed. Thirty-one percent of students failing the NCLEX-RN had previously failed a nursing course. Faculty members believed that students were not well versed in what activities would best prepare a candidate for success on the examination. A standardized examination system, predictive of NCLEX-RN success, was implemented to provide students with immediate scoring and feedback for remediation purposes. The SON also developed a senior-level course in which students received comprehensive support for test anxiety and NCLEX-RN content preparation. Students not passing a required specialty examination met with faculty to develop a study plan for the comprehensive exit examination. Unsuccessful students were required to meet with a faculty mentor weekly for 1 month before attempting the exit examination a second time. Finally, the SON referred students with high test anxiety to the school counseling center. Exit examination pass rates increased from 30% to 89%, and the NCLEX-RN pass rate improved to 90%. To increase conceptual thinking skills, emphasize studentcentered learning, and maintain the program's high NCLEX-RN pass rates, a concept-based curriculum was implemented by one SON (Giddens & Morton, 2010). Standardized examinations were instituted 6 months before graduation to identify at-risk students. Results of standardized examinations showed statistically significant differences for students passing and failing the NCLEX-RN. Following implementation of concept-based curriculum and standardized examinations, first time NCLEX-RN pass rates dropped from 90% before the new curriculum to 83% after the new curriculum. After 2 years of presenting curriculum in a concept-based manner, the NCLEX-RN pass rates returned to 89%. Homard (2013) analyzed the effectiveness of a standardized test package. Data were collected from a first cohort of students who did not use a standardized test package, a second cohort using the package for two semesters, and a third cohort using the package for four semesters. All cohorts took two exit examinations in their final semester. Cohorts 2 and 3 scored significantly higher (scores = 818.35 and 803.92, respectively) on the first comprehensive standardized examination than Cohort 1 (score = 725.98, p b .001). Cohort 3 also scored significantly higher (score = 869.9) on the second comprehensive standardized examination than Cohorts 1 and 2 (scores = 778.7 and 815.75, respectively, p b .001). In addition, Cohort 3 had an 86% NCLEX pass rate compared with 73% for Cohort 1 and 59% for Cohort 2 (p = .003). One SON began using computerized tests in order to expose students to computerized testing, identify students at risk of NCLEXRN failure, and increase NCLEX-RN pass rates (Jacobs & Koehn, 2006). Students were required to take 11 standardized examinations over the course of four semesters. Faculty members' perception was that students were not taking the course examinations seriously prior to implementing a standardized test package. Administered as a final examination, students scoring below 60% were required to participate in remediation. NCLEX-RN pass rates improved from 86% to 92%. Researchers noted that half of the students failing the standardized exit examination passed the NCLEX-RN. NCLEX-RN pass rates at one SON fell to 83% following a decade of pass rates of 90% or higher (March & Ambrose, 2010). Faculty implemented a standardized exit examination during the final senior semester. Students not achieving the passing score were required to participate in remediation, a retest, and a meeting with a faculty member if a passing score was not obtained the second time. Students were required to create individual study plans following receipt of their standardized examination scores. Faculty members reviewed and graded study plans and met with students individually to discuss the plans. Content for a senior-level nursing leadership course was modified to include critical thinking scenarios and new topics, such as delegation, management theories, and cultural diversity. NCLEX-RN pass rates improved to 95% 4 years following the changes in the SON. Between 1998 and 2000, NCLEX-RN pass rates for one school fluctuated between 77% and 85% (McDowell, 2008). The school implemented the knowledge base, anxiety control, test-taking skills framework in an attempt to improve the pass rate. To develop the knowledge base, students were directed to create individual study plans, attempt computerized test questions based on weaknesses, and complete comprehensive examinations predictive of NCLEX-RN success. Students were encouraged to have a positive attitude and 24 B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 vision of passing the NCLEX-RN, use imagery and meditation before and during the examination, employ healthy eating and sleep habits, and participate in diversional activities. Further, students were advised to study both individually and in groups, complete practice examinations independently, and visit the NCLEX-RN testing site prior to the examination date. Test-taking strategies were improved among the students by scheduling time for NCLEX-RN preparation, participating in question drills (50 questions in 1 hr or 100 questions in 2 hr), and completing a minimum of 2,000–4,000 questions in the review process depending on each student's risk for failure. Following implementation of this framework, cohorts of students at this school received a first time pass rate of at least 97% between 2001 and 2006, with 2 years of 100%. Progression policies were changed at another university in an attempt to improve first time NCLEX-RN pass rates (Norton et al., 2006). Policy changes included earning a C or better in nursing courses and only allowing students to retake nursing courses one time before program dismissal. Next, the school began using computerized comprehensive examinations. In addition, a one-credit, yearlong, remediation program that employed case studies and critical thinking activities was required for at-risk students. At-risk students were identified following analysis of scholastic aptitude test scores, computerized examination scores, grades in science and nursing courses, clinical performance, the presence of self-reported test anxiety, and formally diagnosed learning disabilities. All students were invited to attend the one-credit preparation course that helped to de-stigmatize being at risk for failure. A senior capstone course related to leadership and nursing management was replaced with a course that mentored students thorough the NCLEX-RN application process and provided NCLEX-RN practice questions. In a different senior capstone class, students were required to complete and submit results of monthly preparatory examinations on specific content areas needing improvement. In addition, instead of a full semester of clinical practicum during the senior year, students were only allowed to attend the second half of the semester at a practicum site if a 65% was achieved on the predictor examination. The university provided students with half of the tuition for an on-site 3-day NCLEX-RN review course if they passed the NCLEX-RN on the first try within 90 days of course completion. Finally, faculty attended a development workshop focused on writing examination items in the style of the NCLEX-RN. As a result, the university had a significant increase in the percentage of students that passed the examination on the first try. One SON developed and implemented a three-credit course for graduating seniors at risk for failing the NCLEX-RN (Poorman, Mastorovich, Liberto, & Gerwick, 2010). The at-risk seniors were identified if they scored below the 30th percentile on a computerized predictor examination. This course used cognitive–behavioral techniques, metacognitive strategies, and NCLEX-style practice questions to improve the pass rates of at-risk seniors. Students learned cognitive– behavioral techniques, such as using a negative stimulus (e.g., lightly snapping a rubber band on the wrist upon having a negative thought) or employing visual imagery of the day of the NCLEX-RN. Students also learned to read NCLEX-RN practice questions out loud and explain reasoning supporting the selection of answers to others. The first students to complete this course had a 92% first time NCLEX-RN pass rate with an 85% overall class pass rate, whereas the second cohort of students showed a 100% pass rate with an overall class pass rate of 95%. The academic performance of 306 students to determine which courses and standardized examination scores could predict NCLEXRN success was analyzed (Schooley & Kuhn, 2013). The fundamentals examination was the most statistically significant predictor of NCLEX success, followed by a maternity examination and a comprehensive exit examination. Pediatrics, medical–surgical, and maternity nursing course grades were predictors of standardized examination performance. The senior capstone course at this school included advanced medical–surgical nursing concepts and was a significant predictor of standardized exit examination performance. Statistical significance was found at the p b .05 level for each of the listed predictors. One nursing program implemented a comprehensive standardized exit examination for second-semester, junior-level nursing students (Sifford & McDaniel, 2007). This practice was implemented to identify students at risk as early as possible, in order to offer adequate remediation. Those who did not achieve a passing score were required to take the exit examination again in the fall semester of senior year; those who did not pass on the second try were required to enroll in a 15-week remediation course where test-taking skills, test anxiety reduction, and NCLEX-RN practice questions were required. Students attempted the exit examination for a third time at completion of the course. The mean examination score improved from 735.62 to 810.17 (p b .01). After reviewing end-of-program survey comments about examination readiness and considering the learning needs of millennial students, Spalla, Nininger, and Daley (2007) developed a creative approach, called the NCLEX Review Question of the Day program. In this program, an NCLEX-RN-style question was e-mailed every weekday to senior-level students. The students had the option to unsubscribe from the question of the day, but all students chose to participate. Faculty members consulted review books, textbooks, and online sources when creating question-and-answer rationales. Faculty members reported that writing items for this program was labor intensive and that finding reliable information for rationales was challenging. This program encouraged students to take ownership of the NCLEX-RN preparation, enhanced communication between students and faculty, and caught the interest of nonsenior nursing students who wished to participate. In addition, faculty sought informal peer review from faculty at other colleges of nursing to strengthen items used in this program. The performance of 151 recent nursing school graduates was analyzed to measure the relationship of standardized examination results and NCLEX-RN pass rates (Yeom, 2013). In this sample, 22% of test takers did not pass the NCLEX-RN on the first attempt. There was no statistically significant difference between scores on the fundamentals and on the pediatric examinations. Performance on the remaining content examinations (adult medical–surgical, pharmacology, maternal–newborn, mental health, community health, leadership, and management) demonstrated significant difference (p b .00–0.03) between the two groups. Scores for the adult medical– surgical, pharmacology and community health examinations were predictive of NCLEX success and failure (p b .01–.02). Discussion Many SONs have revised programs in order to better equip students for NCLEX-RN success. In addition to supporting NCLEX-RN success, benefits of program revision included improvements in student critical thinking skills and psychosocial support. Critical thinking skills were developed through the use of review courses, study plans, and remediation. The most frequent intervention utilized was the implementation of standardized testing. Use of these tests helped students become familiar with the format of the NCLEX-RN and the style and content of examination items. Further, emotions that come with taking a standardized examination were experienced in the school setting multiple times, as opposed to the first time while taking the NCLEX-RN. Similarly, NCLEX-RN-style questions were used in classrooms or as homework. Benchmark scores or mastery levels were established to help students and faculty track progress toward the level of performance predictive of NCLEX-RN success. Psychosocial support interventions included academic advising; B.L. Quinn et al. / Teaching and Learning in Nursing 13 (2018) 18–26 support groups; implementation of the knowledge base, anxiety control, test-taking skills framework; and measurement of text anxiety with implementation of measures to address such anxieties. Some SONs implemented more rigorous admission and progression policies. Policy changes included raising the passing grade of a nursing course to a C or better, limiting the number of failures of any nursing course or specific nursing courses, such as pharmacology, and requiring a minimum overall, science- and nursing-specific GPA. Failure to meet progression policy requirements resulted in dismissal from the nursing program. Some schools implemented progression polices related to standardized examinations. At some schools, students not meeting benchmark scores were allowed to retest a designated number of times. Continued failure to meet established benchmark scores resulted in remediation or program dismissal. The majority of SONs implemented multifaceted approaches. Although including interventions that addressed test taking and student psychosocial needs was undoubtedly helpful, implementing several interventions at once makes it difficult to discern which interventions contributed most to increased student success. Some SONs required NCLEX-RN preparation for progression in the program, whereas others advised students to engage in NCLEX-RN preparation measures without requiring participation. Some SONs offered or required faculty development workshops that fostered NCLEX-RN success through interventions, such as construction of improved NCLEXRN-style questions to use for class examinations or integrated into class lectures and activities. Another difference noted between SONs involved the timing of intervention implementation. Some SONs started success programs during the first semester, whereas others began interventions during the final semester. It is unclear how the timing of intervention implementation affects NCLEX-RN success; however, it is reasonable to infer that earlier intervention would help students develop strong studying and test-taking habits to employ over the course of their nursing school tenure. Limitations Inclusion criteria for this review were precise. Authors limited inclusion to original research articles and discussion papers related to student success or NCLEX-RN pass rate changes. Upon reviewing the relevant literature examining student and NCLEX-RN success, it was noted that limited data related to associate level programs, only two of the 18 articles included, are available. Another limitation noted was the lack of comment regarding statistical significance of the NCLEX-RN success interventions applied in the included studies. Only two of the 18 articles reported statistical significance of changes to student success following the implementation of interventions. Conclusion NCLEX-RN success is of vital importance to the futures of both SONs and new graduate nurses. SONs cannot operate if enough students do not succeed on this examination. Students failing the NCLEX-RN are at risk for anxiety, grief, and financial stress. Nursing faculty have a duty to prepare students as safe and competent nurses but also for success on the NCLEX-RN. All SONs should support the implementation of NCLEX-RN success interventions that address academic and psychosocial well-being. Future researchers exploring this area should consider calculating and presenting results related to the effect of success interventions on student performance, specifically noting the statistical significance. 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