Running head: CRITICAL THINKING
1
Critical Thinking and Academic Success
in a Practical Nursing Program
Alicia Lundstrom
William Carey University
Joseph and Nancy Fail School of Nursing
Hattiesburg, MS
Submitted in Partial Fulfillment
of NUR 646
Winter Term 2011
CRITICAL THINKING
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Table of Contents
Page
Abstract…...……………………………………………………………………………...
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Dedication………………………………………………………………………………..
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Acknowledgements………………………………………………………………………
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List of Tables……………………………………………………………………………..
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List of Illustrations……………………………………………………………………….
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Section I. Introduction………………………..…………………………………………
Background and Significance…………………………………………………….
Purpose………………………………………………………………………..….
Project Questions………………………………………………………………....
Hypotheses…….………………………………………………………………....
Limitations………………………………………………………………………..
Theoretical Framework…………………………………………………………..
Definitions of Terms…………...………………………………………………...
Summary…………………………………………………………………………
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Section II. Review of Literature…………………………………………………………
Introduction……………………………………………………………………...
Theoretical Literature…………………………………………………………….
Research Literature………………………………………………………………
Summary…………………………………………………………………………
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Section III. Project Methods…………………………………………………………….
Introduction………………………………………………………………………
Methodology………………………………………………………………….....
Setting…………………………………………………………………………....
Sample...………………………………………………………………………....
Procedure...……………………………………………………………………....
Data Collection………………………………………………..………….
Data Analysis………………………...………………………..………....
Summary………...……………………………………………………………….
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Page
Section IV. Project Outcomes…………………………………………………………….
Introduction…………………………………………………………………...…..
Discussion……………………………………………………………………..….
Implications and Recommendations…...……………………………...………….
Implications for Nursing Practice…………………………………………
Implications for Nursing Education……………………………………….
Implications for Nursing Research………………………………………..
Summary…………………………………………………………………………..
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References…………………………………………………………………………………
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Appendices………………………………………………………………………………..
Appendix A. Consent, President of the College………………………………….
Appendix B. Consent, Dean of Healthcare Education…………………………..
Appendix C. Critical Thinking Data Collection Tool.…………………….…….
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Abstract
In an effort to lower attrition and improve academic success, as well as meet the increasing
demands of potential employers for competent nurses, it is essential for nurse educators to
consider factors that may serve as valid predictors of academic success in the program of studies
and licensure. The present study was a quantitative, descriptive, correlational, ex post facto
design. The purpose was to assess associations among score on the HESI®A2 CTE, exit GPA,
academic success (successful program completion), success meeting the benchmark HESI®Exit
Exam score, and success on the National Council Licensure Examination – Practical Nursing
(NCLEX®-PN) first write. A cohort of students (N=60) enrolled in a Practical Nursing program
in a small community college in central Mississippi comprised the convenience sample. Data
were collected via a retrospective records review. Results of the study suggest a statistically
significant association (p<0.05) between critical thinking score on the HESI®A2 CTE and
academic success in a Practical Nursing program, GPA, success in meeting benchmark
expectations established by the Practical Nursing program on the HESI®Exit Examination, and
success on the first write of the NCLEX®-PN. The critical thinking score on the HESI®A2 exam
is, therefore, recommended as a valid assessment criterion in the student admission process to
practical nursing programs.
Keywords: critical thinking, critical thinking skills, critical thinking assessment,
academic admission criteria, academic success, student retention, student attrition,
benchmarks, pre-licensure nursing student, HESI®, NCLEX®-PN ®
CRITICAL THINKING
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Dedication
This project is lovingly dedicated to my family. To my grandfather, Lewis Purvis, whose
ambition in life was to see his grandchildren succeed, I miss you daily. I know you are smiling
down on me now. To my grandmother, Alice Ruth Purvis, thank you for all of the words of
encouragement and good times we share. To my parents, Lavon and Marcia Purvis, the values
you instilled in me and the encouragement you provided are the factors that have encouraged my
continued success. To my children, Cody and Caley, I pray that this project serves as
encouragement for you to fulfill your dreams the same way I have. Finally, to my husband, Jay
Lundstrom, you have always stood by my side and at times carried me on your shoulders. Thank
you for being as proud of this project as I am.
CRITICAL THINKING
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Acknowledgements
I wish to express my sincere appreciation to the people who have assisted me in this
research process. To my major professor, Dr. Mari Wirfs, thank you for assisting me with
developing the study design and your editorial, data management, and statistical analysis
expertise. A special thank you is also extended to the faculty in the graduate program at William
Carey University. I would also like to thank Dr. Betsy Mann, Melanie Pinter, and Theresa Cole
for your unfailing support and encouragement throughout this process.
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List of Tables
Page
Table 2.1.
Distribution of Content for the NCLEX®-PN Test Plan…………..………
25
Table 2.2.
2011 Number of Candidates Taking NCLEX®-PN Examination and
Percent Passing by Type of Candidate…………….……………………...
27
Differences Between Groups for the TABE and Prerequisite Course
Grades……………………………………………………………………..
30
HESI®Exit Examination Scores and the Prediction of NCLEX®-PN
Success…………………………………………………………………….
41
Table 4.1.
Descriptive Statistics: Age………………………………………………..
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Table 4.2.
Descriptive Statistics: Gender and Race………………………………….
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Table 4.3.
Descriptive Statistics: HESI®A2 CTE Scores…………………………….
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Table 4.4.
Intercorrelations: HESI®A2 CTE Scores, GPA, and HESI®
Benchmark Expectations……………………………………..…………..
47
Frequency Distribution: HESI®A2 CTE Scores and Academic Success
in the Practical Nursing Program…………………………………………
48
Frequency Distribution: HESI®A2 CTE Scores and Academic Success
on the NCLEX®-PN First-Write Attempt………………………………..
49
Table 2.3.
Table 3.1.
Table 4.5.
Table 4.6.
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List of Illustrations
Page
Figure 1.1.
Model of Developmental Stages of Critical Thinking…………………….
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CRITICAL THINKING
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Section I
When preparing potential nursing professionals to enter the healthcare industry, nurse
educators recognize the vital importance of graduating students who have the ability to think
critically and provide safe, competent care for healthcare consumers. Similarly, in an effort to
meet the competencies outlined by accrediting bodies, nurse educators must identify students
with the most potential for success in the nursing program of studies. Assessment of critical
thinking ability prior to admission and upon completion of the nursing program can assist nurse
educators in improving attrition and graduating competent and confident nursing students
(Banning, 2006).
Background and Significance
Critical thinking continues to resonate among nurse educators as a topic of discussion
when considering admission criteria as predictors of academic success. Accrediting agencies as
well as healthcare education institutions value student retention. Accordingly, nursing education
programs establish student admission and benchmark criteria in an effort to promote academic
success. However, the ability of nurse educators to assess the critical thinking ability of potential
nursing students is hindered for reasons such as:
1. insufficient knowledge regarding critical thinking;
2. insufficient knowledge regarding methods to incorporate critical thinking into the
nursing curriculum; and
3. insufficient knowledge regarding methods to assess students’ critical thinking
abilities (Vacek, 2009).
Banning (2006) points that the impact of critical thinking as it relates to nursing care may
be viewed from two major perspectives. First and primarily, quality client care is linked to the
CRITICAL THINKING
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ability of nurses to think critically in the planning, provision, and evaluation of care. Research
suggests a strong association between nursing professionals who enter practice in advanced
stages of critical thinking development and improved client outcomes in the acute care setting.
Similarly, persons who are proficient in practicing critical thinking demonstrate the necessary
trait of continuing to develop their own critical thinking skills as well as continuing to grow
professionally (Banning, 2006).
The second perspective emanates from Centers for Medicare and Medicaid Services
(CMS) which began in 2001 with the initiative of pay-for-performance to healthcare facilities.
This reimbursement initiative delineates particular health conditions that are ineligible for
reimbursement in specified healthcare settings. For example, catheter-associated urinary tract
infections and vascular catheter-associated infections are ineligible for reimbursement for
hospitals under the pay-for-performance initiative. As a result, healthcare facilities began to
push harder for improvements in quality of care provided to healthcare consumers. Staff nurses
play an active role in this quality and are held accountable for improvements in the immediate
care as well as progression of care for the client. Quality consumer care requires critical thinking
on the part of nurses charged with the provision of that care (Hines & Yu, 2009).
In an effort to promote critical thinking skills in potential nursing professionals, nurse
educators should work diligently to incorporate critical thinking instruction and practice into the
nursing curriculum. Because of the ongoing knowledge base expansion required of nurses,
development of critical thinking skills is essential to produce competent and confident program
graduates. Further, quantitative research regarding critical thinking skills of nursing program
applicants is important to achieve the goals of programs for student success.
CRITICAL THINKING
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Romeo (2010) suggests that critical thinking dispositions should be evaluated with
beginning and graduating nursing students. However, to measure a student’s critical thinking
disposition as a beginning nursing student and a graduating nursing student would require the use
of a non-nursing specific critical thinking disposition inventory because beginning nursing
students have very limited or no knowledge base related to nursing. While the use of this nonnursing specific tool would quantify data for critical thinking dispositions, the certainty that it
would be an accurate indicator for nursing specific outcomes is debatable. Furthermore, the use
of two different critical thinking inventories would also produce inaccuracies in regard to
assessment of the critical thinking capabilities of potential nursing professionals (Romeo, 2010).
Nurse educators also struggle with developing strategies to implement critical thinking
activities into nursing curricula. In recent years, the implementation of clinical simulation
activities and problem-based learning activities has helped to introduce the concept of critical
thinking exercises into traditional nursing curricula (Kaddoura, 2010). In an effort to ensure that
their programs produce competent new graduates to meet the demands of the healthcare
workforce, nurse educators continue to search for strategies to develop critical thinking skills in
their students, as well as consider the validity of assessing pre-nursing student dispositions
toward critical thinking in the pre-admission screening and selection process.
Purpose
The purpose of this project is to examine associations among the following variables:
1.
critical thinking capabilities of pre-admission nursing students;
2.
successful program completion;
3.
grade point average (GPA) in a Practical Nursing program;
4.
ability to meet benchmark score established by the program on the Health Education
CRITICAL THINKING
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Systems Incorporated (HESI®) Exit Examination; and
5.
success on the National Council Licensure Examination – Practical Nursing
(NCLEX®-PN) on the first write.
Conceptual and research literature was reviewed to ascertain current knowledge in the area of
interest. Results of an examination of critical thinking ability of applicants to a nursing program
and academic success would have implications for examination of the admission practices of
program.
Project Questions
1. Is the cumulative critical thinking score on the HESI®Admission Assessment (A2)
associated with academic success of students enrolled in a Practical Nursing
program?
2. Is the cumulative critical thinking score on the HESI®A2 associated with the exit
GPA of students enrolled in a Practical Nursing program?
3. Is the cumulative critical thinking score on the HESI®A2 associated with benchmark
HESI®Exit Examination score of students enrolled in a Practical Nursing program?
4. Is the cumulative critical thinking score on the HESI®A2 associated with success on
the NCLEX®-PN first-write of students enrolled in a Practical Nursing program?
Hypotheses
To answer the research questions, this investigator posed the following four hypotheses.
Each is stated in the research (H1) and in the null (H0) form. The level of statistical significance
for rejection of null hypotheses was p≤.05.
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research hypothesis 1 (H1:1). Critical thinking score on the HESI®A2 is positively
associated with the academic success of students enrolled in a Practical Nursing program.
null hypothesis 1 (H0:1). There is no association between critical thinking score on the
HESI®A2 and the academic success of students enrolled in a Practical Nursing program.
research hypothesis 2 (H1:2). Critical thinking score on the HESI®A2 is positively
associated with the exit GPA of students enrolled in a Practical Nursing program.
null hypothesis 2 (H0:2). Critical thinking score on the HESI®A2 is not associated with
the exit GPA of students enrolled in a Practical Nursing program.
research hypothesis 3 (H1:3). Critical thinking score on the HESI®A2 is positively
associated with the benchmark HESI® Exit Examination score of students enrolled in a Practical
Nursing program.
null hypothesis 3 (H0:3). Critical thinking score on the HESI®A2 is not associated with
the benchmark HESI® Exit Examination score of students enrolled in a Practical Nursing
program.
research hypothesis 4 (H1:4). Critical thinking score on the HESI®A2 is positively
associated with success on the NCLEX®-PN first-write attempt of students enrolled in a Practical
Nursing program.
null hypothesis 4 (H0:4). Critical thinking score on the HESI®A2 is not associated with
success on the NCLEX®-PN first-write attempt of students enrolled in a Practical Nursing
program.
Limitations
This investigator identified several study limitations. This study was limited to a small
cohort of students enrolled in only one practical nursing program and the program is located in a
CRITICAL THINKING
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rural geographical setting. Data were collected from student records which could result in
missing data for some cases. Academic failure is only one factor resulting in student attrition.
Confounding variables (such as personal reasons, financial issues, change in study focus) were
not addressed in the study. Critical thinking ability in the theoretical realm may not necessarily
transfer to the clinical practice arena. The present study did not account for student attrition due
to clinical performance issues.
Theoretical Framework
According to the Foundation for Critical Thinking (2011), critical thinking is defined as
“the intellectually disciplined process of actively and skillfully conceptualizing, applying,
analyzing, synthesizing, and/or evaluating information gathered from, or generated by,
observation, experience, reflection, reasoning, or communication, as a guide to belief and
action.” The theoretical framework for this study was Richard Paul and Linda Elder’s
developmental stage theory. These theorists identified six sequential stages of critical thinking
development. At stage one is the unreflective thinker. Unreflective thinkers lack the capacity to
identify problems within their own thinking skills. Stage two is the challenged thinker.
Challenged thinkers begin to recognize problems and/or inconsistencies with their thinking
skills. As these problems are recognized, the person enters stage three of development; the
beginning thinker.
Beginning thinkers recognize problems and attempt to correct problems, albeit
sporadically. Stage three tends to be the point of plateau for many individuals. Stage four is the
practicing thinker; one who continues to advance in the skills of thinking and reasoning. Stage
five is the advanced thinker. Advanced thinkers do not have to put forth as much effort to think
critically; however, they do continue to require some extrinsic motivation. At the sixth, most
CRITICAL THINKING
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advanced and fully developed, stage is the accomplished thinker. Accomplished thinkers are
those who think critically without any extrinsic motivation (Paul & Elder, 2009).
Theoretically, students who have entered stage four of critical thinking development
should perform well in both nursing education courses and on NCLEX®. However, continued
success in professions requiring mastery of critical thinking skills requires advancement above
stage four in critical thinking development (Paul & Elder, 2009). These individuals should have
the ability to identify questions and problems, gather and assess relevant information using
abstract ideas, interpret the relevant information, and perform actions based on the relevant
information and standards identified in the profession. Additionally, these individuals should
possess the capabilities of thinking open-mindedly using alternative thought processes,
recognizing and assessing assumptions, implications and consequences, and communicating
effectively with others in order to identify possible solutions to complex problems (The
Foundation for Critical Thinking website, 2011). The goal of the nursing educator is to foster the
critical thinking skills of nursing students so that they become a minimum of stage four thinkers.
A model of Paul and Elder’s (2008) developmental stages of critical thinking as it relates to
nursing education is depicted in Figure 1.1.
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Figure 1.1 Model of Developmental Stages of Critical Thinking
Pre-Admission
Nursing
Student
Nursing
Student
Preparing to
Take Initial
Licensure
Exam
Definition of Terms
academic success.
theoretical definition. According to Ablard (1996), academic success is defined
as the perception of the student in regards to internal and external factors they identify
with academic success.
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operational definition. For the purpose of this study, academic success is defined
as successful completion of the Practical Nursing program East Central Community
College.
critical thinking ability/skill.
theoretical definition. According to The Foundation for Critical Thinking (2011),
the following skills are essential to an effective critical thinker:
1. raises vital questions and problems, formulating them clearly and concisely;
2. gathers and assesses relevant information, using abstract ideas to interpret it
effectively, comes to well-reasoned conclusions and solutions, testing them
against relevant criteria and standards;
3. thinks open-mindedly within alternative systems of thought, recognizing and
assessing, as need be, their assumptions, implications, and practical
consequences; and
4. communicates effectively with others in figuring out solutions to complex
problems.
operational definition. For the purpose of this study, critical thinking ability/skill
is defined as the score on the critical thinking component of the HESI®A2 (CTE) prior to
admission to the Practical Nursing program.
grade point average (GPA).
theoretical definition. As defined in Merriam-Webster’s Online Dictionary
(2011), GPA is the average obtained by adding the total number of grade points earned
and dividing it by the total number of credit hours attempted.
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operational definition. For the purpose of this study, GPA is defined as the
resulting three digit value (on a four-point scale, rounded to the nearest hundredth)
obtained by summing the total number of grade points earned in the Practical Nursing
curriculum and dividing that number by the total number of credit hours attempted earned
in the Practical Nursing at East Central Community College.
HESI®exit examination benchmark score.
theoretical definition. According to the Evolve Learning System website (2011),
benchmark score indicating an average probability of student success on NCLEX®-PN is
greater than or equal to 850.
operational definition. For the purpose of this study, the HESI®Exit Examination
benchmark score for prediction of NCLEX®-PN success is a minimum score of 850.
NCLEX-PN®.
theoretical definition. The NCLEX®-PN is a computer-based assessment
administered to candidates who have completed a Practical Nursing program at an
accredited institution. The assessment is designed to measure competencies of the
candidates to perform safely as a newly-licensed nurse (National Council of State Boards
of Nursing website, 2012).
operational definition. For the purpose of this study, NCLEX®-PN is defined as
a computer-based assessment administered to candidates who have completed a Practical
Nursing program at an accredited institution, in an effort to measure competencies of the
candidates to perform safely as a newly-licensed nurse.
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NCLEX®-PN First Write Attempt.
theoretical definition. According to the Mississippi Board of Nursing (2008), the
NCLEX®-PN first-write attempt is the initial attempt to pass the computer-based
NCLEX®-PN examination by the student who has successfully completed an accredited
Practical Nursing program in Mississippi.
operational definition. For the purpose of this study, NCLEX®-PN first-write
attempt is defined as the initial attempt to pass the computer-based NCLEX®-PN
examination by the student who has successfully completed the Practical Nursing
program at East Central Community College.
Summary
Nursing professionals must possess the ability to think critically to be able to provide
competent and confident care to healthcare consumers. Nurse educators have the very important
responsibility of guiding potential nursing professionals through the critical thinking processes
and applying the skills in the clinical practice setting. However, nurse educators face challenges
in accomplishing this task. These challenges include, but are not limited to:
1. lack of a nursing-specific definition of critical thinking;
2. difficulty evaluating critical thinking in nursing students;
3. lack of a nursing-specific tool to measure nursing students’ ability to think critically;
and
4. inability to evaluate critical thinking capabilities at the entry level and graduating
level with the same tool (Romeo, 2010).
In conclusion, it is the responsibility of nurse educators to incorporate critical thinking
into the nursing curriculum, to help students learn to apply critical thinking in the clinical arena
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as well as develop methods to evaluate the critical thinking skills of nursing students prior to or
at the beginning, during, and on completion of their nursing education. Nurse educators not only
bear the responsibility of teaching students a knowledge base, but they also bear the
responsibility of ensuring that potential nursing professionals possess the ability to continue to
expand upon this knowledge base. For this reason, it is imperative that nurse educators embrace
critical thinking in their instructional skill repertoires. In so doing, the desired outcome of
graduating confident and competent nursing professionals who are successful on the NCLEX®PN may be achieved. This section presented the background and significance of the study, the
purpose, research questions, hypotheses, limitations, theoretical framework, and definitions of
terms for the present study. In the next section, Section II, this author presents an overview of
the conceptual and theoretical literature relevant to the study.
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Section II
Review of Literature
Introduction
The following section examines current literature related to critical thinking in nursing
education. The literature review was conducted by hand, internet, and online library database
searches from literature published January, 2000 to May, 2011. The Cumulative Index for
Nursing and Allied Health Literature (CINAHL) was the primary resource for internet-based
searches. Search words utilized in various combinations included, but were not limited to:
critical thinking, critical thinking ability/skills, critical thinking assessment, academic admission
criteria, academic success, student retention, student attrition, benchmarks, pre-licensure nursing
student, HESI®, and NCLEX®-PN. Research related to critical thinking examination prior to
student acceptance into a nursing program is very limited. Quantitative research regarding the
role of critical thinking in continued academic success was also limited. However, numerous
studies were available that examined the role of critical thinking and NCLEX® success rates. A
review of the relevant theoretical and research literature follows.
Theoretical Literature
Critical thinking became a primary focus in nursing education in the 1990s. Critical
thinking in the nursing profession is essential in the provision of high quality nursing care. The
National League for Nursing (NLN) and the American Association of Colleges of Nursing
(AACN) cite critical thinking as a core competency for nursing education. Accrediting agencies
such as the National League for Nursing Accrediting Commission (NLNAC) and the
Commission on Collegiate Nursing Education (CCNE) all require nursing education programs to
include critical thinking components in program curriculums, as well as develop methods to
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assess the ability of students to meet these required outcomes. By ensuring that students possess
the ability to think critically, the nursing education institution assists in training nurses who are
professionally accountable (Rubenfeld & Scheffer, 2006).
According to The Foundation for Critical Thinking (2011), critical thinking is defined as
that mode of thinking – about any subject, content, or problem – in which the thinker improves
the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking
and imposing intellectual standards upon them. The ongoing development of critical thinking
skills requires the thinker to continuously analyze thought processes in an effort to prevent
distorted thinking. Practicing thinkers are able to process information based on principles of
intelligibility, correctness, meticulousness, reliability, importance, substantiated evidence, good
reasons, profundity, extent, and fairness (The Foundation for Critical Thinking website, 2011).
Healthcare employers value critical thinking skills. Educational institutions must
graduate students capable of meeting the challenges of the emerging workforce. According to
Elder (2000), employees are challenged by the continued growth and complexity of job
requirements, technological advancements that replace jobs, and continued growth of required
employee involvement in efforts to ensure quality improvement. Large amounts of revenue are
lost due to inattention to the principles of intelligibility, correctness, meticulousness, reliability,
importance, substantiated evidence, good reasons, profundity, extent, and fairness. The educator
is challenged to foster the critical thinking skills of students in order to ensure the successful
transition from student to professional (Elder, 2000).
Critical thinking is an essential component in the provision of safe care for healthcare
consumers. Heaslip (2008) argues that critical thinking in nursing directly impacts clinical
decision-making skills and these skills are based on eight elements of thought:
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1. the problem, question, concern, or issue;
2. the purpose or goal;
3. the frame of reference;
4. the assumptions held true;
5. the central concepts, ideas, principles, and theories used in reasoning;
6. the evidence, data, or information provided to substantiate the reasoning;
7. the interpretations, inferences, and reasoning that lead to the conclusion; and
8. the implications and consequences that follow from the solution.
Nurse educators focus on fostering the continued growth of these skills through classroom and
clinical experiences aimed at requiring the use of these elements (Heaslip, 2008).
Billings and Halstead (2009) examined the role of critical thinking in nursing education,
stating that nursing is a profession that is practiced in a complex environment on complex
beings. Furthermore, continuing technological advancements require that nurses be more
inclined to examine thought processes behind patient care, rather than just perform the
psychomotor skills associated with patient care. Therefore, it is the responsibility of nursing
education institutions to examine the ability of students to think critically prior to admission and
upon completion of a nursing program (Billings & Halstead, 2009).
The most effective way to determine the role of a critical thinking assessment tool in the
admission criteria of a particular nursing program is to examine the relative scores of a critical
thinking assessment tool measured with defined academic success of the institution. Billings and
Halstead (2009) discussed three different tools that can be utilized in the assessment of critical
thinking skills in students. However, the fallacy with each of these tools is the lack of nursingspecific assessments that can be utilized to gauge the ability of students to think critically
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(Billings & Halstead, 2009). The three tools discussed by Billings and Halstead are reviewed
below.
The first tool, the Watson-Glaser Critical Thinking Appraisal (WGCTA), consists of
different problems encountered in daily living. The WGCTA measures five different areas.
These areas include deduction, inference, recognition of assumptions, interpretation, and
evaluation of arguments. The test consists of multiple choice questions, with each different area
containing a total of 16 questions. Each different area is weighted evenly, and the maximum
score on the examination is 80. Billings and Halstead (2009) reported on a study performed by
Bauwens and Gerhard in 1987 in which the WGCTA was used to predict academic success on
NCLEX® examination scores. The study tested the critical thinking capacity of nursing students
prior to admission and upon completion of the nursing program. The results of the study found
that there were no significant changes in the result of critical thinking scores on this tool between
the times administered (Billings & Halstead, 2009).
The second critical thinking inventory is the California Critical Thinking Skills Test
(CCTST). This inventory is a standardized 34-question multiple choice test. The inventory
provides an overall score, as well as a score of subscales which include analysis, evaluation,
inference, deductive reasoning, and inductive reasoning. However, the literature related to the
use of the CCTST with nursing students is very limited (Billings & Halstead, 2009).
The third instrument discussed by Billings and Halstead (2009) is the California Critical
Thinking Disposition Inventory (CCTDI). This inventory is a 75-item inventory which utilizes a
six-point Likert scale to gauge the critical thinking dispositions of students in seven different
subscales. These subscales include open-mindedness, analyticity, maturity, truth-seeking,
systematicity, inquisitiveness, and self-confidence. The inventory reports an overall score, as
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well as a score in each of the seven different subscales. Similar to the CCTST, the CCTDI has
not been utilized extensively in nursing education; therefore, available literature related to the
use of this tool is also limited (Billings & Halstead, 2009).
The NCLEX® is a computer-based assessment developed by the National Council for
State Boards of Nursing (NCSBN) utilized by state boards of nursing to assess the ability of
entry-level nurses to practice in a competent manner. The NCLEX® examination consists of
two versions– NCLEX®-RN and NCLEX®-PN. Requirements to take the NCLEX® examination
are not established by NCSBN, but rather by individual state boards of nursing (National Council
of State Boards of Nursing website, 2012). Qualified applicants who meet of exceed the
benchmark passing score may be issued a license to practice nursing in the state (providing there
are no other disqualifying factors).
The NCLEX®-PN utilizes the principles of Bloom’s Taxonomy to assess the ability of
students to perform at the application level or higher. The test plan is divided into four major
client needs categories, with two of these categories divided into subcategories. These categories
and their distribution of content on the exam are illustrated in Table 2.1.
Table 2.1: Distribution of Content for the NCLEX®-PN Test Plan
Client Needs
Safe and Effective Care Environment
 Coordinated Care
 Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
 Basic Care and Comfort
 Pharmacological Therapies
 Reduction of Risk Potential
 Physiological Adaptations
(2011 NCLEX®-PN Detailed Test Plan, 2011)
Percentage of Items from Each
Category/Subcategory
13 – 19%
11 – 17%
7 – 13%
7 – 13%
9 – 15%
11– 17%
9 – 15%
9 – 15%
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The student must be able to integrate concepts from the social sciences and biological sciences,
as well as demonstrate clinical problem-solving ability (nursing process), caring, communication
and documentation, and teaching and learning in addition to the four client needs categories
specified in the 2011 NCLEX®-PN detailed test plan (2011 NCLEX®-PN Detailed Test Plan,
2011).
The computer-based NCLEX®-PN consists of a databank of test questions ranging from
85 to 205 questions, of which 25 are pretest items that are not scored. A five-hour time limit is
allotted for completion of the exam and begins when the candidate sits down and begins the
tutorial (and includes scheduled/unscheduled breaks). The test consists of different item formats
including multiple choice, multiple response, fill-in-the-blank, hot spot, exhibit, drag and drop,
ordered response, audio, and graphic (2011 NCLEX®-PN Detailed Test Plan, 2011).
The number of items on the test for a given candidate is based on the computerized
adaptive testing (CAT) model which targets items to the candidate’s ability by reviewing
answers to previously answered questions. If the candidate responds to an item correctly, the
CAT model searches the database for an item that is approximately equal in difficulty to the
current question. If the candidate replies incorrectly, the CAT model re-estimates the
candidate’s ability and chooses another item based on the determination. This is an ongoing
process until it is determined with 95% probability that the candidate has the ability to practice
nursing safely in an entry-level position (2011 NCLEX®-PN Detailed Test Plan, 2011).
Two constraints are placed on NCLEX®-PN in order to assure validity of the exam to
determine the ability of the candidate to practice safely. For candidates requiring multiple
attempts on the NCLEX®-PN, the computer prevents the questions from previous attempts
(within the last year) from re-appearing on the candidate’s exam. The second constraint ensures
CRITICAL THINKING
27
that the test plan specifications set forth by the four major client needs categories are met with
each attempt by the candidate (2011 NCLEX®-PN Detailed Test Plan, 2011).
NCSBN maintains records of NCLEX®-PN attempts. The data for 2011 is presented in
Table 2.2
Table 2.2: 2011 Number of Candidates Taking NCLEX®-PN Examination and Percent Passing,
by Type of Candidate
PN
Type of
Candidate
First Time, US
Educated
Repeat, US
Educated
First Time,
Internationally
Educated
Repeat,
Internationally
Educated
All Candidates
Jan–Mar
20113
#
%
Apr-Jun
20114
#
%
Jul-Sep
2011
#
%
Oct-Dec
2011
#
%
Year to Date
2011
#
%
16,521
87.58
13,121
82.08
22,291
87.00
13,401
80.53
65,334
84.83
3,255
42.70
3,429
27.47
3,502
35.29
3,789
34.57
13,975
34.91
211
51.66
214
36.45
159
49.06
171
46.20
755
45.56
226
27.88
244
16.39
214
12.62
201
16.42
885
18.42
20,213
79.31
17,008
69.56
26,166
79.24
17,562
69.55
80,949
75.12
1 The # symbol denotes the number of candidates who took the exam.
2 The % symbol denotes the percentage of candidates that passed the exam.
3 The PN passing standard was -0.37 logits.
4 Beginning April 1, 2011 the PN passing standard was changed from -0.37 to -0.27 logits.
(National Council of State Boards of Nursing website, 2012)
Nurse educators bear the responsibility of preparing students for NCLEX®-PN and must
face this challenge by exposing students to similar assessment measures utilized by NCLEX®PN. HESI® exams are an assessment tool used by many nursing education institutions to assist
with this process. HESI® offers numerous nursing-specific exams including but not limited to
admission assessments (with/without critical thinking), specialty examinations, and exit
examinations (Evolve Learning System website, 2011).
CRITICAL THINKING
28
The HESI®A2 is a computer-based assessment exam consisting of 275 multiple-choice
items, with four choices per item. The test consists of five categories: science (Biology,
Chemistry, and Anatomy and Physiology), vocabulary and general knowledge, reading
comprehension, grammar, and basic math skills. The admission assessment may or may not be
administered with additional components including learning style, critical thinking, and
personality style (Evolve Learning System website, 2011).
The HESI®A2 CTE is a 30-item computer-based assessment of critical thinking ability.
This exam is a multiple-choice test, with four options for each test item. All answers are correct;
however, each choice reflects a different degree of critical thinking skill. Possible score ranges
from 0 to 1000, with a higher score indicating a higher level of ability to think critically within
the discipline of nursing. The recommended time to complete the exam is 30 minutes, and the
CTE score is not included in the comprehensive HESI®A2 score (Evolve Learning System
website, 2011).
Academic success directly impacts the student, employer, and economy. Research
conducted by the National Center for Education Statistics (2009) indicates that a higher level of
education in adults often leads to higher employment rates and higher salaries. Similarly,
academic success transcends to individuals who are more stable in employment, more likely to
have health insurance, be less dependent on public assistance programs, and be more involved in
their communities. Crime rates were also lower among individuals with a higher level of
education (National Center for Education Statistics website, 2009).
Nursing student attrition is a major cause for concern. In order to meet the demands of
the ongoing nursing shortage, retention of nursing students is a challenge facing nurse educators.
Stickney (2006) conducted a study of factors affecting Practical Nursing student attrition for 153
CRITICAL THINKING
29
Practical Nursing students in a community college in central Florida. The sample was divided
into two groups: the group who completed the one-year program on schedule (retention group)
and the group who did not (attrition group). The researcher examined variables including scores
on the Test of Adult Basic Education (TABE) and grades in required prerequisite courses.
Demographic variables including age, gender, and race were also investigated (Stickney, 2008).
Attrition rates for the demographic variables age and gender did not reveal statistically
significant results; whereas, attrition rates for the demographic variable race were statistically
significant. A cross-tabulation analysis of data revealed a higher attrition rate for male students
(37.5%) than female students (36.6%). Students 36 to 45 years-of-age (n=13) had an attrition
rate of 48.1% (40% for ages 46 years and older (n=8) and between 33% and 40% for all other
age ranges). The attrition rate for Caucasian students (30%) was significantly lower than the
attrition rate for African American students (48%), Hispanic students (44.4%) and Asian students
(50%) (Stickney, 2008).
Stickney (2008) found that the variables TABE scores and grades in required prerequisite
courses were statistically different (p<.05) among minority and majority groups. Table 2.3
presents these findings. Stickney (2008) recommended implementation of a retention program
dealing with academic learning and study skills in pre-admission nursing students. According to
this researcher, early interventions in academic areas as identified by the TABE would assist in
improving attrition rates among Practical Nursing students.
CRITICAL THINKING
30
Table 2.3: Differences Between Groups for the TABE and Prerequisite Course Grades
Measure
TABE math
 White
 Minority
TABE verbal
 White
 Minority
TABE reading
 White
 Minority
Introduction to Health Care course
 White
 Minority
Medical Terminology course
 White
 Minority
(Stickney, 2008)
M
SD
t
11.51
10.08
2.07
2.33
12.03
9.47
1.79
3.19
12.34
10.93
1.23
2.48
3.41
3.05
0.68
0.72
3.28
2.85
p
3.98
0.000
6.34
0.000
4.65
0.000
3.17
0.002
3.30
0.001
0.77
0.81
Student progression is important for the student, the nursing program, and the educational
institution. A study of 556 associate degree nursing students in central Texas was aimed at
identifying factors associated with student progression. Of the original sample (N=556), 385 of
the students successfully completed the program and completed the first-write attempt for the
NCLEX®-PN. The students were then divided into two groups. Group one (n=328) was
comprised of students who successfully completed the program and passed NCLEX®-PN on the
first-write. Group two (n=58) was comprised of students who successfully completed the
program and did not pass NCLEX®-PN on the first-write (Tipton et al., 2008).
The researchers examined variables associated with progression including academic
performance in nursing courses, scores on the Nurse Entrance Test (NET), the type of test taker,
and presence of stressors. Researchers conducted an independent samples t-test (equal variances
not assumed) of GPA in nursing courses which revealed that small differences in nursing course
CRITICAL THINKING
31
grades could identify students who are at risk to be unsuccessful (Group 1, M=79.60; Group 2,
M=76.88) (Tipton et al., 2008).
The NET is a standardized exam that assesses information on the examinee’s reading and
math abilities, types of stressors, and test-taker profile. Researchers found that NET scores did
not significantly predict students’ ability to progress in nursing education by utilizing a smaller
randomized sample (N=68) to perform a t-test between the two groups (t (66)=.907, p=.368)
(Tipton et al., 2008).
The NET also categorizes test takers as frustrated, instructional, or independent.
Frustrated test takers have difficulty taking multiple choice and true/false tests. Instructional test
takers have difficulty determining the most appropriate option on multiple choice examinations.
Independent test takers are considered to have minimal difficulty with multiple-choice and
true/false examinations. A chi-square analysis suggested that the proportion of test-taking types
between the two groups was not statistically significant (?2(2)=.3296, p=.192) (Tipton et al.,
2008).
Stressors are commonly thought to play a significant role in student progression/attrition.
The NET identifies stressors including family, social, money/time, academics, and/or work.
Separate Goodness of Fit Chi-square analyses conducted between the two groups suggested no
significant differences with any of the stressors (all ? 2s >.05). However, the setting for the
study employed a licensed counselor who provided group stress management sessions and
individual counseling sessions for students included in the study on an as needed basis (Tipton et
al., 2008).
CRITICAL THINKING
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Research Literature
Quantitative studies of critical thinking as a predictor of success in pre-admission nursing
students are very limited. Some of the reasons are difficulty in evaluating levels of critical
thinking, the lack of nursing specific tools designed to measure critical thinking skills, and the
assumption by professionals that success on the NCLEX®-PN identifies competency in critical
thinking. While the majority of questions on the NCLEX®-PN are application and analysis level
on Bloom’s Taxonomy, it is incorrect to assume that a student possesses adequate critical
thinking capabilities to care for complex beings in complex environments based on these results
(Romeo, 2010).
Research conducted in the Netherlands demonstrated the effect of critical thinking
instruction in students required to make complex decisions and perform in complex
environments. The research was composed of two field studies in crisis management situations
for military personnel. In the first study, printed scenarios were presented to 16 officers of the
Royal Netherlands Air Force. Eight of the officers were provided an additional instruction sheet
explaining critical thinking. Results of the study indicated that the students who were provided
with the critical thinking instruction sheet obtained higher grades than the group who did not
receive the critical thinking instruction sheet; however, the results were not statistically
significant (Helsdingen, Van den Bosch, Van Gog, & Van Merrienboer, 2010).
The second field study was implemented in a high fidelity simulation setting.
Participants were divided into eight member teams, with one team receiving critical thinking
instruction throughout the simulation scenario. According to investigator reports, the team that
received the critical thinking instruction throughout the scenario scored significantly higher
(M=2.88, SD=0.37, p≤.05) on the decision-making process portion of the simulation scenario test
CRITICAL THINKING
33
and the decision outcomes portion of the simulation scenario test (M=2.42, SD=0.36, p≤.05) than
the control group. The results of the control group on the decision making process portion of the
exam were M=2.20, SD=0.23 and the results on the decision outcomes portion of the exam were
M=1.69, SD=0.39 (Helsdingen et al., 2010).
Although this study was not nursing-specific, findings supported the hypothesis that
critical thinking and decision outcomes share a direct relationship. That is, the ability of a
student to think critically directly influences the decisions that are made and ultimately, the
effects of those decisions. This is a key concept in critical thinking instruction and evaluation for
nurse educators.
Nursing education institutions face challenges in trying to prepare students to enter the
complex world of the nursing profession, while ensuring that students enter the workforce with a
passion for providing compassionate nursing care that endures throughout their career in nursing.
A descriptive, correlational study performed by Zurmehly (2008) examined the relations of
educational preparation, autonomy, and critical thinking to nursing job satisfaction. The study
included a sample size of 140 registered nurses who practiced in medical-surgical,
administrative, and home health care settings. The study utilized the WGCTA and the
Minnesota Satisfaction Questionnaire (Zurmehly, 2008).
Data analysis revealed a statistically significant (r=.538, p<.05) relationship between
autonomy and job satisfaction and a statistically significant relationship (r=.442, p<.05) between
scores on the WGCTA and job satisfaction. Educational preparation and job satisfaction data
indicated bachelor’s prepared nurses were most satisfied (M=66.25), followed by master’s
prepared nurses (M=63.30), associate’s degree nurses (M=56.57), and diploma nurses
(M=44.26). A multiple regression analysis of the job satisfaction model utilizing all variables
CRITICAL THINKING
34
demonstrated that the largest contributor to job satisfaction was critical thinking ability, followed
by self-perceived autonomy and then educational level (Zurmehly, 2008).
Wolkowitz and Kelley (2010) studied the academic predictors of success in a nursing
program. Their study examined the use of standardized tests including the Scholastic Aptitude
Test (SAT), the American College Test (ACT), the Nursing Entrance Test (NET), and the Test of
Essential Academic Skills (TEAS), for preadmission into a nursing program against Assessment
Technologies Institute’s (ATI) RN Fundamentals assessment for students in the first semester of
a nursing program. The SAT and the ACT are standardized tests used primarily to gain
acceptance to a post-secondary institution, while the NET, TEAS, and ATI RN Fundamentals
assessment are utilized primarily in nursing education. A total of 4,105 nursing students’ scores
on the TEAS and ATI RN Fundamentals assessment were evaluated. Data were gathered only
for first-time examination attempts (Wolkowitz & Kelley, 2010).
The TEAS provides an overall score and sub-scores for reading, mathematics, science,
and English and the ATI RN Fundamental assessment is an assessment tool utilized in nursing
education to gauge the success of students enrolled in courses fundamental to nursing education.
The investigators found that sub-scores of the TEAS showed a low correlation between the score
on the admission assessment and performance on the ATI RN Fundamentals assessment.
However, the amount of variance for the science sub-scores (r=0.15) indicated that this score is
accurate 14.9% of the time in predicting success on the ATI RN Fundamental Assessment
(Wolkowitz & Kelley, 2010).
Romeo (2010) surveyed the research literature on the measurement of critical thinking
capabilities and usefulness of critical thinking as a prediction of NCLEX® performance. This
investigator discovered a large volume of research on critical thinking in nursing education and
CRITICAL THINKING
35
found similar problems in each. Lack of a nursing-specific tool and nursing definition of critical
thinking were cited as common core problems. Also, Romeo (2010) cited student attrition as a
primary problem in researchers’ attempts to obtain quantitative data in the pre-admission stages
and graduate stages of nursing education. Furthermore, any research done to quantify critical
thinking as a predictor of academic success on the NCLEX® must utilize comparison analysis
between students who are successful and those who are not successful (Romeo, 2010).
An expected outcome of nursing education is the ability of graduates to be able to
perform timely while caring for clients in a complex and continuously changing environment. In
order to meet these expectations, newly graduated nurses must be able to think critically. In a
study conducted in the Netherlands, researchers attempted to describe critical thinking
dispositions among newly graduated nurses. They examined student background variables as
predictors of critical thinking disposition (Wangensteen, Johansson, Bjorkstrom, & Nordstrom,
2010).
This cross-sectional, descriptive study sample was drawn from a population of 1,900
newly graduated nursing students in 18 different colleges in Norway. Of the 656 volunteers
responding to an invitation to participate, 42 did not meet inclusion criteria and were excluded
from the study. A total of 614 (N=1,900, n=614 [32.3%]) nurses comprised the convenience
sample and completed a study-specific questionnaire and the CCTDI. In analyzing the data, the
researchers found that 90% of the newly graduated nurses scored above the recommended score
of 40 on the CCTDI inquisitiveness subscale of the tool, indicating a strong disposition toward
continued learning (Wangensteen et al., 2010).
Associations between the background variables, age and university education prior to
nursing education were statistically significant. Persons 30 years-of-age and older had higher
CRITICAL THINKING
36
CCTDI scores than persons younger than 30 (88% vs. 75%). Additionally, people with
university education prior to entry into nursing education had higher scores on the CCTDI (87%
vs. 79%). Results of this study indicated that older age and post-secondary preparation prior to
admission into nursing education are associated with greater critical thinking ability
(Wangensteen et al., 2010).
Rogers (2010) conducted a qualitative study at a school of nursing that admitted
approximately 96 new students annually. The school had a retention rate of 80% and the
NCLEX®-PN first time pass rate was approximately 89%. Faculty and students were
interviewed with a series of questions aimed at identifying factors that the individuals felt
secured success in the nursing program and emerging trends were identified. The emerging
trends were categorized into three different subgroups: student related, collaborative, and
curriculum related. Critical thinking skills emerged as a recurring theme among both faculty and
students (Rogers, 2010).
In a study of 54 fourth semester nursing students enrolled in a 17-week NCLEX®-PN
review course, Lyons (2008) utilized the ATI Critical Thinking Test to measure the critical
thinking skills of students prior to, and upon completion, of the course. Participants were
divided into two groups: a problem-based learning group and a lecture group. The problembased learning group was assigned tasks to help foster critical thinking skills and the lecture
group received traditional classroom lecture. Lyons (2008) reported that 88.9% of the
participants passed the NCLEX®-PN on the first-write within six months of completion of the
review course. First-time pass rates between the problem-based learning group and the lecture
group were statistically significant, with 93% (n=27) of participants in the problem-based
CRITICAL THINKING
37
learning group passing the NCLEX®-PN on the first-write and only 85% (n=27) of the lecture
group passing on the first-write (Lyons, 2008).
Although not a statistically significant finding, results of the ATI Critical Thinking
Examination revealed higher scores for the lecture group (M=65.5, p=NS) than for the problembased learning group (M=64.4, p=NS). The post-course mean score for the students who
participated in the lecture group was 68.9 and the post-course mean score for the problem-based
learning group was 67.9. Lyons (2008) concluded that the students receiving additional
instruction in critical thinking achieved better results from the review course than the students
who received traditional lecture.
Higgins (2005) investigated relationships between program completion and NCLEX®-PN
pass rates, prerequisite courses, preadmission test components, demographic variables, HESI®
Exit Examination scores, and nursing skills laboratory scores. The study sample was composed
of 213 records of previously enrolled associate degree nursing students of a program in Texas.
Higgins (2005) reported that a significant difference between successful completion of the
program and prerequisite course grades in Anatomy and Physiology II (r =.152, p<.05) and
Microbiology (R2=.191, p<.05). Results of comparisons with English and mathematics courses
were not statistically significant. Additionally, the study results revealed that scores on the
preadmission assessment demonstrated a statistically significant correlation with completion of
the nursing program: reading (r=0.124, p<.05), science (r= 0.184, p<.05), and math (r= 0.129,
p<.05). The data further iterates the notion that critical thinking ability is a major factor in the
future academic success of potential nursing students (Higgins, 2005).
CRITICAL THINKING
38
Summary
Nurse educators face challenges in the attainment of student success, from program
admission to program completion to licensure. Student attrition is a major problem for students
and nurse educators alike. In an attempt to reduce attrition rates, educators review and adjust
admission criteria based on simple program-level statistics, accrediting agency requirements, and
current research literature. But as multiple variables may potentially influence academic success,
identification and quantification of variables associated with academic success is a complex task
requiring valid measures.
Section II presented a review of theoretical and research literature. The role of critical
thinking in the changing face of the nursing profession is a call to action for nurse educators to
continue researching the value and utility of assessing critical thinking in pre-licensure nursing
students, as an indicator, or predictor, of academic success. In order to accomplish this task, this
researcher believes it wise for nurse educators to examine program admission criteria and
evaluate pre-licensure students’ critical thinking abilities prior to entering the nursing program
and again upon completion of the program. The research reviewed herein does suggest a
positive correlation between the ability to think critically and successful progression in nursing
education. Additionally, critical thinking capacity of nursing students is a significant indicator of
the ability of potential nursing professionals to think autonomously and deliver safe, quality
nursing care. Section III is a discussion of project methods in the present study, including the
setting, sample, and data collection and analysis procedures.
CRITICAL THINKING
39
Section III
Project Methods
Introduction
As indicated in the review of literature, the ability to think critically has been identified
by employers and the profession as a desired trait among newly graduated nurses. Furthermore,
the evaluation of the student’s ability to critically think must be a factor in the nursing program
admission process (Zurmehly, 2008). To accomplish this requires that nurse educators have
reliable methods to quantify the ability of pre-licensure and graduate nursing students to think
critically. Section III presents the methodology for testing the hypotheses and answering the
research questions and in the present study. The study is designed (setting, sample, data
collection, and data analysis) to examine relationships among the HESI®A2 Critical Thinking
Exam (CTE) score, academic success, GPA, ability to meet benchmark scores established by the
Practical Nursing program on the HESI® Exit Examination, and success on NCLEX®-PN first
write attempt in a cohort of Practical Nursing students.
Methodology
This study was quantitative, correlational, ex post facto, descriptive research. Data were
obtained via a retrospective review of student records from Fall, 2009 through Fall, 2010.
Variables in the review were scores on the HESI®A2 CTE, academic success rates in the
Practical Nursing program, exit GPA, benchmark scores established by the Practical Nursing
program on the HESI®Exit Examination, and academic success on NCLEX®-PN first write
attempt.
The HESI®A2 CTE is a 30-item computer-based assessment of critical thinking ability.
This exam is a multiple-choice test, with four options for each test item. All answers are correct;
CRITICAL THINKING
40
however, each choice reflects a different degree of critical thinking skill. Possible score ranges
from 0 to 1000, with a higher score indicating a higher level of ability to think critically within
the discipline of nursing. The recommended time to complete the exam is 30 minutes, and the
CTE score is not included in the comprehensive HESI®A2 score (Evolve Learning System
website, 2011). After data was collected, nursing faculty was educated regarding the correlation
between critical thinking capabilities and the above mentioned factors in an effort to encourage
nursing faculty to evaluate current admission criteria for the Practical Nursing program in order
to foster improved academic success rates.
GPA was defined as the resulting three digit value (on a four-point scale, rounded to the
nearest hundredth) obtained by summing the total number of grade points earned in the Practical
Nursing curriculum and dividing that number by the total number of credit hours attempted
earned in the Practical Nursing at East Central Community College. This value represents the
GPA of the Practical Nursing program only, as no prerequisite courses are required for
admission to the program.
The HESI® Exit Examination is a 150-item computer-based assessment designed to
identify strengths and weaknesses of Practical Nursing students nearing program completion.
The examination is scored using the HESI® Predictability Model (HPM) which is a mathematical
formula that considers the difficulty of each item in order to determine the student’s performance
on the exam. Scores range from 0 to 1000. Two versions of the examination are available and
remediation is recommended based upon the results (Evolve Learning System website, 2011).
HESI® utilizes research findings to establish recommended benchmark scores on the exit
examination, in an effort to predict NCLEX®-PN success. Table 3.1 lists the results of the
findings.
CRITICAL THINKING
41
Table 3.1: HESI® Exit Examination Scores and the Prediction of NCLEX®-PN Success
HESI® Scoring Interval
Description
A. 950 <
OUTSTANDING probability of passing
B. 900 – 949
EXCELLENT probability of passing
C. 850 – 899
AVERAGE probability of passing
D. 800 – 849
Below average probability of passing
E. 750 – 799
Additional preparation needed
F. 700 – 749
Serious preparation needed
G. 650 – 699
Grave danger of failing
H. < 649
Poor performance expected
(Evolve Learning System website, 2011)
The benchmark score established by the Practical Nursing program is 850 and is based on
recommendations by HESI for student to have average probability of passing NCLEX®-PN firstwrite.
Setting
The setting for this study was a Practical Nursing program in a school of nursing in a
small, rural community college in Central Mississippi. Student records are stored in the
healthcare education building. The school admits approximately 30 students to the program
annually. The HESI®A2 CTE is currently administered to students seeking enrollment in the
program; however, the scores are not evaluated for admission to the program.
CRITICAL THINKING
42
Sample
A total of 60 Practical Nursing student records were audited from the classes of students
admitted in Fall, 2009 and Fall, 2010. Inclusion criteria for study participation included a score
on the HESI®A2 CTE and admission to the Practical Nursing program. Students who did not
meet the above inclusion criteria were excluded. Institutional and student data were coded using
numbers or pseudonyms and all files were retained in a confidential and secure place.
The ages of students ranged from 19 years to 54 years (M=30.37). There were six (10%)
males and 54 (90%) females. The majority of students resided primarily in the five-county rural
district served by the community college: Leake, Neshoba, Newton, Scott, and Winston counties.
There were 35 (58.33%) Caucasian students and 25 (41.67%) African-American students
included in the study. There were no other races represented in the sample.
Procedure
data collection.
Prior to proceeding with data collection, written consent was requested and received from
the President of the college (Appendix A) and the dean of the school of nursing (Appendix B).
The researcher was available to answer questions regarding the research prior to consent being
obtained. All parties were provided with two contact telephone numbers for further information
regarding the study, including that of the researcher and the dean of the School of Nursing at
William Carey University.
In order to facilitate data collection and recording, an investigator-developed data
collection tool was utilized (Appendix C). Student record audits were conducted by this
researcher of the class of students admitted in Fall, 2009 and the Fall, 2010. Demographic data
included the student age, race and gender. Admission scores on the critical thinking portion of
CRITICAL THINKING
43
the HESI®A2 exam, scores on the first HESI® Exit Examination, student grades and successful
program completion were obtained in the records audit and successful completion of NCLEX®PN on the first write was obtained from the office of the Dean.
data analysis.
Data were analyzed using Winks SDA software. Descriptive statistics were obtained for
variables age, gender, race, HESI®A2 CTE score, GPA, HESI®Exit Exam score, and NCLEX®-PN
first-write. The Pearson Product Moment Correlation Coefficient (Pearson r) was applied to the data to
test correlations among HESI®A2 CTE score, GPA, and HESI® Exit Examination scores. The level of
statistical probability for rejection of null hypotheses (H01, H02, H03, H04) and acceptance of research
hypotheses (H11, H12, H13, H14) was p<.05.
Summary
The purpose of the present study was to examine relationships among the HESI®A2
Critical Thinking Exam (CTE) score, academic success, GPA, benchmark scores established by
the Practical Nursing program on the HESI® Exit Examination, and success on NCLEX®-PN
first- write attempt in a cohort of Practical Nursing students. Section III presented the
methodology for testing the hypothesis and answering the research questions. Section IV
presents a discussion of findings and implications for nursing practice, nursing education, and
nursing research.
CRITICAL THINKING
44
Section IV
Project Outcomes
Introduction
Nurse educators are challenged to assess the potential for success of potential nursing
students. For this reason, it is imperative that nurse educators take an active role in gathering
and interpreting data thought to be potential predictors of academic success. Critical thinking
ability has been identified by researchers as a significant factor in the prediction of academic
success. Therefore, nurse educators are wise to assess the critical thinking capabilities of
potential nursing students toward the goal of improving student outcomes. These important
outcomes include academic success in the program of studies and success on the NCLEX®-PN
first write. The purpose of the present study was to examine relationships among the HESI®A2
Critical Thinking Exam (CTE) score, academic success, GPA, ability to meet benchmark scores
established by the Practical Nursing program on the HESI®Exit Examination, and success on
NCLEX®-PN first- write attempt in a cohort of Practical Nursing students. Section IV is a
discussion of the study outcomes with implications and recommendations posited by this
investigator.
Discussion
Descriptive statistics were applied to the data to examine frequencies and central
tendencies of the variables. Descriptive analysis of data includes the mean of the group of
numbers, standard deviation from the mean, the minimum observed number, and the maximum
observed number. Frequency distributions allow the researcher to see the most frequently
occurring scores, as well as identify any patterns in the distribution of scores (LoBiondo-Wood
& Haber, 2010). Descriptive statistics were utilized to describe the demographic data: age,
CRITICAL THINKING
45
gender, and race. Descriptive statistics were also utilized to analyze the HESI®A2 CTE scores of
students admitted into the Practical Nursing program.
A total of 60 student records were audited and the data pertaining to the variables of
interest were entered into the data analysis procedures. The demographic variable age with
descriptive statistics is presented in Table 4.1. The variables gender and race with descriptive
statistics are presented in Table 4.2. Student scores on the HESI®A2 CTE with descriptive
statistics are presented in Table 4.3.
Table 4.1: DESCRIPTIVE STATISTICS: AGE
N=60
FIELD
----AGE
N
60
MEAN
---30.37
STD
--9.96
SEM
--1.29
MIN
--19
MAX
--54
As depicted in table 4.1, the mean age of students admitted into the Practical Nursing
program was 30.37 with a standard deviation of 9.96 years. The sample group ranged in age
from 19 to 54 years.
Table 4.2: DESCRIPTIVE STATISTICS: GENDER AND RACE
N=60
Frequency Table 4.2.1: GENDER
Cumulative
Cumulative
GENDER
Frequency
Percent
Frequency
Percent
----------------------------------------------------------Male
6
10.0
6
10.0
Female
54
90.0
60
100.0
Frequency Table 4.2.2: RACE
Cumulative
Cumulative
RACE
Frequency
Percent
Frequency
Percent
----------------------------------------------------------Caucasian
35
58.33
35
58.33
African-American
25
41.67
60
100.0
CRITICAL THINKING
46
As depicted in table 4.2, six (10%) male students and 54 (90%) female students were
admitted into the Practical Nursing program for the inclusion time period. Of the 60 students, 35
(58.33%) students were Caucasian and 25 (41.67%) students were African-American. There
were no other races represented in the sample group.
Table 4.3: DESCRIPTIVE STATISTICS: HESI®A2 CTE SCORES
N=60
FIELD
----CT SCORE
N
60
MEAN
---792.67
STD
--64.88
SEM
--8.38
MIN
--550
MAX
--900
As depicted in table 4.3, the mean score on the HESI®A2 CTE for the sample group was 792.67
with a standard deviation of 64.88. The scores ranged from 550 to 900.
According to Burns and Grove (2009), a descriptive correlational design investigates
relationships existing in a situation. The design focuses specifically on relationships among study
variables. Data pertaining to the ability of the student score on the HESI®A2 CTE to predict
GPA, the ability of the student to meet the established benchmark of the Practical Nursing
program on the HESI® Exit Examination, the evaluation of successful completion of the Practical
Nursing program, and success on the NCLEX®-PN examination on the first write was analyzed
utilizing the Pearson product moment correlation coefficient (Pearson r, [r]). Student scores on
the HESI®A2 CTE were entered as the independent variable in the Pearson equation. GPA and
score on the HESI® Exit Examination were entered into the Pearson equation as the dependent
variables. GPA of students who successfully completed the Practical Nursing program ranged
from 2.50 [250] to 3.49 [349] (M=3.10 [310], SD=22.87). HESI® Exit Examination scores
ranged from 670 to 1134 (M=845, SD=99.10).
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47
Table 4.4: INTERCORRELATION: HESI®A2 CTE SCORES, GPA, AND HESI®EXIT EXAM
BENCHMARK EXPECTATIONS
HESI®A2 CTE SCORES
GPA
.309
(.016*)
[ 60]
HESI® EXIT EXAM
.291
(.024*)
[ 60]
* p<.05
Results of the Pearson correlation analysis as depicted in table 4.4 indicate a positive
correlation (r =.309, p =.016) between scores on the HESI®A2 CTE and GPA. Similarly, the
data also indicate a statistically significant (p<.05) positive correlation (r =.291, p=.024) between
scores on the HESI®A2 CTE and meeting benchmark requirements established by the Practical
Nursing program on the HESI® Exit Examination. That is, greater ability to think critically, as
measured by the HESI®A2 CTE prior to admission to the Practical Nursing program, is
significantly associated with greater academic success (as measured by GPA) in the nursing
program of studies.
Frequency distribution tables were generated to identify associations between HESI®A2
CTE Scores and academic success in the Practical Nursing program (table 4.5) and associations
between HESI®A2 CTE scores and academic success on the NCLEX®-PN first-write attempt
(Table 4.6).
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48
Table 4.5: FREQUENCY DISTRIBUTION: HESI®A2 CTE SCORES AND ACADEMIC
SUCCESS IN THE PRACTICAL NURSING PROGRAM
N=60
Frequency Table 4.5.1: Students Successful in the Practical Nursing Program
Cumulative Cumulative
HESI®A2 CTE SCORE Frequency Percent
Frequency
Percent
------------------------------------------------------------740
1
2.94
1
2.94
750
1
2.94
2
5.88
760
4
11.76
6
17.65
770
1
2.94
7
20.59
780
5
14.71
12
35.29
790
3
8.82
15
44.12
800
3
8.82
18
52.94
810
2
5.88
20
58.82
820
2
5.88
22
64.71
830
1
2.94
23
67.65
840
5
14.71
28
82.35
860
1
2.94
29
85.29
870
1
2.94
30
88.24
880
2
5.88
32
94.12
890
1
2.94
33
97.06
900
1
2.94
34
100.0
Frequency Table 4.5.2: Students Unsuccessful in the Practical Nursing Program
Cumulative
Cumulative
HESI®A2 CTE SCORE
Frequency Percent
Frequency
Percent
---------------------------------------------------------------550
1
3.85
1
3.85
600
1
3.85
2
7.69
680
2
7.69
4
15.38
710
1
3.85
5
19.23
720
1
3.85
6
23.08
740
1
3.85
7
26.92
750
1
3.85
8
30.77
760
2
7.69
10
38.46
770
3
11.54
13
50.0
780
2
7.69
15
57.69
790
2
7.69
17
65.38
800
1
3.85
18
69.23
820
2
7.69
20
76.92
830
1
3.85
21
80.77
840
1
3.85
22
84.62
860
1
3.85
23
88.46
880
2
7.69
25
96.15
890
1
3.85
26
100.0
CRITICAL THINKING
49
Table 4.5 indicates that students scoring below 740 on the HESI®A2 CTE were
unsuccessful in the nursing program (p<.05). The frequency table does not categorize data of
students who scored above 740 on the HESI®A2 CTE who were unsuccessful. Other factors
contributing to non-success in the program include personal reasons, financial issues, change in
study focus, and other non-related items are not accounted for in the frequency table.
Table 4.6 FREQUENCY DISTRIBUTION: HESI®A2 CTE SCORES AND STUDENT
SUCCESS ON NCLEX®-PN FIRST-WRITE ATTEMPT
N=60
Frequency Table 4.6.1: Students Successful on NCLEX®-PN First Write Attempt
Cumulative
Cumulative
HESI®A2 CTE SCORE
Frequency Percent
Frequency
Percent
-------------------------------------------------------------------750
1
3.45
1
3.45
760
2
6.9
3
10.34
770
1
3.45
4
13.79
780
5
17.24
9
31.03
790
2
6.9
11
37.93
800
3
10.34
14
48.28
810
2
6.9
16
55.17
820
2
6.9
18
62.07
830
1
3.45
19
65.52
840
5
17.24
24
82.76
860
1
3.45
25
86.21
870
1
3.45
26
89.66
880
1
3.45
27
93.1
890
1
3.45
28
96.55
900
1
3.45
29
100.0
Frequency Table 4.6.2: Students Unsuccessful on NCLEX®-PN First-Write Attempt
Cumulative Cumulative
HESI®A2 CTE SCORE
Frequency Percent
Frequency
Percent
------------------------------------------------------------------740
1
50.0
1
50.0
880
1
50.0
2
100.0
Ninety-four percent of students who scored above 740 on the HESI®A2 CTE were
successful on the first-write of the NCLEX®-PN (Table 4.6.A). According to the results of the
data analysis as depicted in tables 4.5 through 4.6, nurse educators may consider critical thinking
CRITICAL THINKING
50
score on the HESI®A2 examination as a predictor of academic and NCLEX®-PN success among
potential nursing students.
Implications and Recommendations
implications for nursing practice.
The ability to think critically is essential to the success of newly graduated nursing
students. However, a portion of the task of continuing to foster the ability of students to achieve
life-long learning lies with employers. In an effort to secure positive patient outcomes, the
present research suggests that employers offer critical thinking activities in the form of
continuing education in to foster the continued development of critical thinking (as depicted in
the Model of Developmental Stages of Critical Thinking, figure 1.1).
implications for nursing education.
Outcomes of the present study suggest that a score of 740 or above on the HESI®A2 CTE
is positively associated with academic success, GPA, ability of the student to meet benchmark
expectations established by the Practical Nursing program, and success on NCLEX®-PN first
write attempts. Therefore, it is the recommendation of this investigator that nurse educators in
Practical Nursing programs consider the score obtained on the HESI®A2 CTE in admission
requirements in an effort to lower attrition and foster improved student outcomes during the
academic program of studies and NCLEX®-PN success on the first-write.
implications for nursing research.
This investigator recommends replication of the present study in larger cohorts of
Practical Nursing students. Further research regarding the use of the HESI®A2 CTE score, as
well as comparisons with other measurements of critical thinking prior to admission and upon
completion of a nursing program are recommended to further assess the significance of critical
CRITICAL THINKING
51
thinking ability in the success of student outcomes. This author also recommends replication of
this study in populations of associate degree and baccalaureate degree nursing programs and
programs in urban as well as rural geographical locations. Lastly, this investigator recommends
research is warranted related to the ability of nursing students to advance above stage four on the
Model of Developmental Stages of Critical Thinking (figure 1.1) after graduation, entering the
nursing profession, and at various points in time as they gain experience in the practice arena.
Additional research may hopefully yield more data to quantify the impact of critical thinking
skills in both nursing education and the nursing profession.
Summary
Nurturing and encouraging the ability of nursing students to think critically has become a
primary task of the nurse educator. Encouraging students to think critically helps students
become independent thinkers who are capable of making timely, complex decisions in complex
environments. The present study has demonstrated that critical thinking ability is a factor that is
significantly associated with success in a Practical Nursing program in central Mississippi. This
finding supports prior research that the requirements of nurses to make complex decisions in
continuously changing and complex environments makes critical thinking skills a primary task
for nursing students to master.
Nurse educators face the challenge of evaluating critical thinking ability prior to students’
admission and on nursing program completion. Additionally, nurse educators also face the
challenge of fostering nursing students’ desires to become lifelong learners in order to apply
critical thinking skills in their professional practice as healthcare providers. By encouraging the
continuing development of students’ critical thinking skills, nurse educators contribute to the
ongoing development of competent and confident nursing professionals.
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52
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Appendix A
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Appendix B
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Appendix C
Critical Thinking Data Collection Tool
Age of Student:
_________
Gender of Student:
Race of Student:
◌
Male
◌
Caucasian
◌
Female
◌
African
American
Hispanic
Native
American
Other
◌
◌
◌
Critical Thinking Score:
PN Program GPA:
__________
_________
Student Score on HESI®Exit #1:
Student Successful on NCLEX®-PN 1st Write:
__________
◌
Yes
◌
No
Program Completion:
◌
Successful
◌
Unsuccessful