IMPACT OF HESI SPECIALTY EXAMS: THE NINTH HESI EXIT EXAM VALIDITY STUDY ELIZABETH L. ZWEIGHAFT, EDD, RN Using an ex post facto, nonexperimental design, this, the ninth validity study of Elsevier's HESI Exit Exam (E 2 ), reexamined the predictive accuracy of the E 2. The value of administering HESI Specialty Exams within the nursing curriculum in terms of E 2 scores was also investigated. The sample was composed of nursing students (N = 3,790) from 63 randomly selected schools 26 baccalaureate, 31 associate degree, and 6 diploma programs throughout the United States who took the E 2 between September 2008 and August 2009. As in the previous 8 studies, the E 2 was found to be highly accurate (96.61%) in predicting success on the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Findings also indicated that students who took one or more HESI Specialty Exams during their nursing curriculum had a significantly higher mean E 2 score (P.0001) than students who did not take HESI Specialty Exams during their nursing curriculum. Of the 8 HESI Specialty Exams investigated, scores on the Critical Care, Pediatrics, and Medical Surgical specialty exams were most predictive of NCLEX-RN success. Schools of nursing that used HESI Specialty Exams as course final exams had a significantly higher mean E 2 score (P b.01) than schools that used the exams for remediation and practice. (Index words: HESI Specialty Exams; HESI Exit Exam; NCLEX-RN success) J Prof Nurs 29:S10 S16, 2013. 2013 Elsevier Inc. All rights reserved. SINCE 1999, EIGHT STUDIES have investigated the validity of Elsevier's HESI Exit Exam (E 2 ) in predicting success on the National Council Licensure Examination for Registered Nurses (NCLEX-RN), and findings indicate that the E 2 is highly predictive (96.36% to 99.16%) of NCLEX-RN success. However, to date, no studies have investigated the value of administering HESI Specialty Exams throughout the nursing curriculum. Of interest to the researcher was whether these specialty exams help prepare students for the E 2 and ultimately for the NCLEX-RN. Therefore, the purpose of this study was to (a) reexamine the accuracy of the E 2 in terms of predicting NCLEX-RN success and (b) investigate the value of administering HESI Specialty Exams in terms of Associate Dean and Assistant Professor, Felician College, Lodi, NJ. Disclosure Statement: Dr. Zweighaft has participated in research activities and received presentation honoraria from HESI Review & Testing within the past 3 years. Address correspondence to Dr. Zweighaft: Felician College, 262 South Main Street, Lodi, NJ 07644-2117. E-mail: zweighafte@ felician.edu 8755-7223/12/$ - see front matter E 2 scores. An ex post facto, nonexperimental research design was used to address the purpose of this study. Background Poorman (2011) stated that faculty should spend a majority of their time teaching students, not evaluating them, and further acknowledged that the process of becoming a better evaluator makes for a better teacher. Considering the current faculty shortage and the complexity of providing sound testing throughout the curriculum, many schools are outsourcing a portion of their testing to companies that provide standardized exams so that faculty have more time to devote to what they do best teaching (Morrison, Nibert, & Flick, 2006). E 2 and HESI Specialty Exam test items are critical thinking questions that are used to measure students' knowledge of nursing content and their ability to apply concepts to clinical problems. These test items follow the model for test item writing described by Morrison et al. and are written by nurse experts, including nurse educators, practitioners, and researchers. After questions are submitted to Elsevier by these experts, they undergo a rigorous editing process and are piloted on S10 http://dx.doi.org/10.1016/j.profnurs.2012.06.011 Journal of Professional Nursing, Vol 29, No. 2S (March/April), 2013: pp S10 S16 2013 Elsevier Inc. All rights reserved.
IMPACT OF HESI SPECIALTY EXAMS S11 various HESI exams with thousands of uses. The items are edited again based on item analysis data obtained from the piloting procedure (Morrison, Adamson, Nibert, & Hsia, 2004). This is an arduous process that most nursing faculty do not have the time or resources to implement. Therefore, faculties are increasingly turning to standardized testing to evaluate students and the nursing curriculum. Eight previously conducted studies have confirmed that the E 2 is a highly accurate predictor of NCLEX-RN success (Adamson & Britt, 2009; Langford & Young, 2013; Lauchner, Newman, & Britt, 1999; Lewis, 2005; Newman, Britt, & Lauchner, 2000; Nibert & Young, 2001; Nibert, Young, & Adamson, 2002; Young & Willson, 2012). The use of the E 2 within schools of nursing has been the subject of numerous studies (Bentley, 2006; Daley, Kirkpatrick, Frazier, Chung, & Moser, 2003; DiBartolo & Seldomridge, 2005; Frith, Sewell, & Clark, 2005). Harding (2010) conducted a systematic literature review regarding the predictability of exit exams and reported that the E 2 was highly accurate in predicting NCLEX-RN success but not failure. However, Nibert et al. (2002) reported that as E 2 scores decreased, the percentage of NCLEX-RN failures significantly increased. Furthermore, Nibert et al. (2006) stated that the purpose of obtaining such data was to assess students' risk for NCLEX-RN failure so that faculty could assist them in remediating deficit areas, thereby enhancing the probability of students' passing the NCLEX-RN. The E 2 and HESI Specialty Exams provide a measure of external curriculum evaluation, which compares a student or group of students to the overall student population, and is conducted by sources outside the college or university (Morrison et al., 2004). The summary reports provided by the E 2 include content area scores that can guide students' remediation efforts as well as evaluate curricular strengths and weaknesses. HESI Specialty Exams provide similar summary reports, but the data described in these reports are related to one specific clinical specialty area. Although a plethora of research has been conducted regarding the validity of the E 2 (Adamson & Britt, 2009; Langford & Young, 2013; Lauchner et al., 1999; Lewis, 2005; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002; Young & Willson, 2012), no research has been conducted to determine the worth of administering HESI Specialty Exams throughout the nursing curriculum. Conceptual Framework Classical test theory described by Crocker and Algina (1986) and critical thinking theory described by Paul (1990) were used as the theoretical basis for developing a model for writing critical thinking test items described by Morrison et al. (2006). This model was used to formulate the conceptual framework for the eight previously conducted studies that examined the accuracy of the E 2 in predicting NCLEX-RN success. The model, described in detail by Morrison et al. (2004), was also used for this study. Instruments Three instruments were used to collect the data for this study: the E 2, HESI Specialty Exams, and the Ninth Validity Study Questionnaire. The E 2 and HESI Specialty Exams are produced by Elsevier, and the Ninth Validity Study Questionnaire was designed by the researcher. E 2 and HESI Specialty Exams The E 2 is a 160-item comprehensive exam, of which 10 items are pilot items that do not contribute to the students' scores. It is often administered during the final semester, or quarter, of the nursing curriculum. The E 2 test blueprint is reflective of the NCLEX-RN test plan (National Council of State Boards of Nursing [NCSBN], 2010). HESI Specialty Exams are 55-item content-focused exams. Five of the questions included in these exams are pilot items and do not contribute to the student's scores. These exams are typically administered at the conclusion of a nursing course and are usually counted as some portion of the student's final grade in that course. This study focused on the HESI Specialty Exams that had testing cohorts of greater than 300, which included the following eight exams: Critical Care, Fundamentals, Maternity, Management, Medical Surgical, Pediatrics, Psychiatric Mental Health, and Pharmacology. Questions on the E 2 and the HESI Specialty Exams are reflective of the test item formats used by the NCSBN during the study period and include multiple-choice, multiple-response, fill-in-the-blank, hot-spot, chart/exhibit, and drag-and-drop items (NCSBN, 2010). Scores on the E 2 and the HESI Specialty Exams range from 0 to approximately 1800, with the highest score dependent on the difficulty level of the test items included in the exam. The reliability of the E 2 and the HESI Specialty Exams is determined by calculating the Kuder Richardson Formula 20 (KR20) for every exam that is returned to Elsevier for scoring. An estimated KR20 for these exams is calculated prior to their administration and is based on data obtained from all prior administrations of the test items included in the exam (Morrison et al., 2004). The estimated reliability, or KR20, for the E 2 s and the HESI Specialty Exams administered during the study period ranged from 0.84 to 0.92. The validity of the E 2 has been established by eight previously conducted studies. With a total student sample of 45,325 for the prior studies, findings indicated that the E 2 was 96.36% to 99.16% accurate in predicting NCLEX-RN success (Adamson & Britt, 2009; Langford & Young, 2013; Lauchner et al., 1999; Lewis, 2005; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002; Young & Willson, 2012). Measurement of content validity for the HESI Specialty Exams is an ongoing process. Course syllabi from colleges and universities across the U.S. are reviewed by Elsevier's nurse educators and researchers
S12 ELIZABETH L. ZWEIGHAFT at least three times annually to determine what content is currently being taught in schools of nursing. HESI Specialty Exams are designed to evaluate the clinical content described in these syllabi (Morrison et al.). Ninth Validity Study Questionnaire The Ninth Validity Study Questionnaire, which was used to collect data for this investigation, was designed and pretested by the researcher. It consisted of 19 multiplechoice questions with open comment fields. The purpose of the questionnaire was to obtain information from participating deans and directors regarding policies established at their college or university for administration of the E 2 and HESI Specialty Exams. Specifically, the participating deans and directors were asked to describe policies related to the use of E 2 scores and HESI Specialty Exam scores for benchmarking and remediation. The questionnaire also requested information regarding student outcomes on the NCLEX-RN. To maintain confidentiality, deans and directors removed students' identifying information before uploading their responses to Elsevier. Methods After institutional review board approval was obtained, participating schools of nursing reported school policies, strategies, and deidentified student cohort information. An ex post facto, nonexperimental design was used to compare E 2 scores and NCLEX-RN outcomes of students who took one or more HESI Specialty Exams during their nursing curriculum (users) with E 2 scores of students who did not take HESI Specialty Exams during their nursing curriculum (nonusers). The population consisted of students who took the E 2 between September 1, 2008, and August 31, 2009. A list of user and nonuser schools was enumerated, and a random number generator was applied. Deans and directors from 97 randomly selected schools of nursing were invited to participate in the study. The random sample of schools was stratified using the three program types baccalaureate (BSN), associate degree (ADN), and diploma to match the distribution of candidates from each program type who took the NCLEX-RN during the study period. Those who did not respond within two weeks received a follow-up e-mail or telephone call, and two weeks after the initial follow-up, if there was still no response, a final follow-up was made to ensure that the surveys were received. Of the 97 schools invited to participate, deans and directors from 63 (64.95%) schools responded to the questionnaire, 26 BSN, 31 ADN, and 6 diploma programs. Of the 63 responding deans and directors, 43 (68.25%) reported that they were users of specialty exams, and 20 (31.75%) reported that they were nonusers of specialty exams. From the 63 randomly selected schools, 3,790 nursing students participated in this study: 1,489 (39.29%) BSN students, 2,103 (55.49%) ADN students, and 198 (5.22%) diploma students. A power analysis indicated that the sample size was adequate for this investigation. Of the 3,790 students, 2,332 (61.53%) were users of specialty exams, and 1,458 (38.47%) were nonusers of specialty exams. Table 1 describes users and nonusers of HESI Specialty Exams by program type. Findings Eight previously conducted studies determined the predictive accuracy of the E 2 based on students who scored 900 and higher, which is the score at which Elsevier describes students as predicted to pass the NCLEX-RN. Of the 3,790 students who participated in this study, 1,394 (36.78%) scored 900 and higher on the E 2. NCLEX-RN results were reported for 1,326 of these 1,394 students, and 1,281 (96.61%) of the 1,326 students for whom licensure exam outcomes were available passed the NCLEX-RN on their first attempt. A Welch Satterthwaite's t test was used to determine if there was a difference in mean E 2 scores of users and nonusers of specialty exams. The mean E 2 score for users was 865.7, and the mean E 2 score for nonusers was 837.3. Findings indicated that users had significantly higher E 2 scores than nonusers (P.0001), which according to Salkind (2010) is a medium effect size of 0.24. E 2 scores were further analyzed by program type. The mean E 2 score for BSN users was 848.4, and the mean E 2 score for BSN nonusers was 824.5. Findings indicated that BSN users had significantly higher E 2 scores than BSN nonusers (P =.0004), which according to Salkind is a small effect size of 0.19. The mean E 2 score for ADN users was 877.1, and the mean E 2 score for ADN nonusers was 847.4. Findings indicated that ADN users had significantly higher E 2 scores than ADN nonusers (P.0001), which according to Salkind is a large effect size of 0.85. The mean E 2 score for diploma users was 866.4, and the mean E 2 score for diploma nonusers was 830.3. Findings indicated that the E 2 scores of diploma users and nonusers were not significantly different (see Table 2). Odds ratio analyses were conducted to determine which of the eight HESI Specialty Exams that had testing cohorts of greater than 300 were predictive of NCLEX- RN success. The score most often established by schools of nursing as an E 2 benchmark is 850 (Young & Willson, 2012). Therefore, scores of 850 and higher were used to conduct these odds ratio analyses. Findings indicated that all eight HESI Specialty Exams were significantly predictive (P =.0001 to.0034) of NCLEX-RN success. The three most predictive specialty exams of NCLEX-RN success were Critical Care, Pediatrics, and Medical Surgical (see Table 3). Users of the specialty exams were asked how they implemented these exams within their curriculum. Responding deans and directors from 36 of the 63 schools (57.14%) answered the question. Of the 36 respondents, 6 (16.67%) indicated that the specialty exams were used as final exams, 6 (16.67%) for practice, 9 (25.00%) for remediation only, and 15 (41.66%) responded other. Student self-assessment, knowledge of national ranking, and as a course test grade were the most often cited other implementation strategies.
IMPACT OF HESI SPECIALTY EXAMS S13 Table 1. Users and Nonusers of HESI Specialty Exams by Program Type Users and nonusers Total BSN Associate Diploma School users 43 (68.25%) 15 (57.77%) 23 (74.19%) 5 (83.33%) School nonusers 20 (31.75%) 11 (42.31%) 8 (25.81%) 1 (16.66%) Total schools 63 (100.00%) 26 (100.00%) 31 (100.00%) 6 (100.00%) Student users 2,332 (61.53%) 862 (57.89%) 1,295 (61.58%) 175 (88.38%) Student nonusers 1,458 (38.47%) 627 (42.11%) 808 (38.42%) 23 (11.62%) Total students 3,790 (100.00%) 1,489 (100.00%) 2,103 (100.00%) 198 (100.00%) Additionally, some faculty reported that specialty exam cohort scores were used as a component of their systematic curriculum evaluation. Table 4 describes these frequencies. The mean E 2 score for schools that administered HESI Specialty Exams as course final exams was 875.2 (N = 524), and the mean E 2 score for schools that used the specialty exams for remediation and practice was 859.5 (N = 868). A Welch Satterthwaite's t test indicated that schools that implemented HESI Specialty Exams as course final exams had a significantly higher mean E 2 score (P b.01) than schools that implemented HESI Specialty Exams for practice and remediation, which according to Salkind (2010) is a small effect size of 0.15 (see Table 5). Discussion and Recommendations The predictive accuracy of the E 2 for this ninth validity study (96.61%) remains within the range of the eight previous validity studies (96.36% to 99.16%) that were conducted over the past 13 years. Once again, the E 2 was determined to be a highly accurate predictor of NCLEX- RN success. Because of its predictability, scoring data provided by the E 2 can confidently be used by nursing faculty and students to guide remediation, thereby reducing students' risk of failing the licensing exam and increasing NCLEX-RN pass rates. Additionally, E 2 data can be tracked over time and used as a measure of external curriculum evaluation, which provides quantifiable evidence of curricular and faculty effectiveness that can be included in schools' accreditation or reaccreditation reports. Each previously conducted E 2 validity study examined one or more variables other than the predictive accuracy of the E 2. For the first time, the value of administering HESI Specialty Exams throughout the nursing curriculum was investigated in terms of E 2 scores. Findings indicated that students benefited from taking one or more HESI Specialty Exams during their nursing curriculum. They had a significantly higher mean E 2 score than those who did not take HESI Specialty Exams during their nursing curriculum. Newman et al. (2000) reported that students with high E 2 scores are significantly more likely to pass the NCLEX-RN than those with low E 2 scores. Furthermore, when comparing E 2 scoring intervals, Nibert et al. (2002) and Lewis (2005) found that NCLEX-RN failures increase significantly as E 2 scores decrease. Therefore, it can be conjectured that if administering HESI Specialty Exams helps students achieve higher E 2 scores, then it is likely that administering HESI Specialty Exams throughout the nursing curriculum helps candidates achieve NCLEX-RN success. The use of HESI Specialty Exams exposes students to standardized testing early in the curriculum, which probably explains why users of specialty exams had higher E 2 scores than nonusers of specialty exams. Like the E 2, HESI Specialty Exams contain nationally normed, critical thinking test items. Unlike the E 2, which is usually administered during the last semester or quarter of the curriculum when little time remains for remediation before taking the NCLEX-RN, HESI Specialty Exams are administered throughout the nursing curriculum. Consequently, remediation needs can be identified early and addressed as the student progresses through the nursing program. The scoring reports provided by the specialty exams are similar to those provided by the E 2, but the specialty exam reports focus on one clinical area Table 2. E 2 Scores of Users and Nonusers of HESI Specialty Exams by Program Type Program type Specialty exam use Number of students E 2 mean score Statistical findings SD df t test P BSN Users 862 848.4 110.7 1,145 3.53.0004 Nonusers 627 824.5 141.0 ADN Users 1,295 877.1 107.4 2,101 6.14.0001 Nonusers 808 847.4 108.3 Diploma Users 175 866.4 97.5 196 1.68.0943 Nonusers 23 830.3 91.6 Total Users 2,332 865.7 108.7 3,655 12.42.0001 Nonusers 1,458 837.3 123.7 P b.001. P.0001.
S14 ELIZABETH L. ZWEIGHAFT Table 3. Odds of Passing the NCLEX-RN When Scoring 850 and Higher on HESI Specialty Exams 95% Confidence interval Specialty exam n Odds ratio Lower Upper P Critical care 328 11.164 2.598 47.971 b.0001 Pediatrics 655 5.510 2.643 11.489 b.0001 Medical-Surgical 1,099 5.502 3.388 8.932 b.0001 Fundamentals 600 3.710 1.783 7.726.0002 Psychiatric 1,350 3.390 2.250 5.107 b.0001 Maternity 802 3.373 1.999 5.691 b.0001 Management 693 2.984 1.785 4.989 b.0001 Pharmacology 590 2.122 1.271 3.543.0034 P b.05. P b.001. P.0001. Odds ratio of passing the NCLEX-RN. and provide an in-depth evaluation of students' mastery of the content and concepts related to that particular clinical area. Standardized testing administered throughout the curriculum also provides a measure of external curriculum evaluation. Like E 2 data, specialty exam data can be tracked over time to assess faculty and curricular effectiveness, and these data also provide quantifiable evidence that can be included in schools' accreditation or reaccreditation reports. Of the 63 participating schools of nursing, deans and directors from 36 (57.14%) schools responded to the question regarding strategies used to implement HESI Specialty Exams within their school of nursing. Of the 36 respondents to this question, 41.67% indicated that the specialty exams were used for practice and remediation, whereas 16.67% of the respondents indicated that they used the specialty exams as a final exam. Although replacing final exams with standardized exams relieves faculty from the arduous task of writing test items and constructing final exams, relatively few schools chose this implementation strategy. However, the mean E 2 score was higher for schools that administered the HESI Specialty Exams as course final exams than the mean E 2 score for schools that used these exams for practice and remediation. It is likely that the consequences associated with taking HESI Specialty Exams as course final exams incentivizes students to prepare more diligently for these exams, which in turn helps them prepare for the E 2 and ultimately for the licensing exam. Although faculty reported implementing HESI Specialty Exams for student self-assessment, course grades, and for comparison to national norms, 41.66% chose the open dialog response other to this question. Information provided by this open dialog choice can be used to design future questionnaires so that subsequent studies can compare more effectively specific implementation strategies for specialty exams. It is possible that as more studies are conducted that investigate the use of HESI Specialty Exams throughout nursing curriculums, faculty may become more comfortable with outsourcing testing to companies that specialize in the scientific development of standardized exams, thereby enabling faculty to focus their time and effort on what they do best teaching nursing. This initial study of HESI Specialty Exams compared student outcomes of those who took one or more specialty exams with those who took no specialty exams users and nonusers. These dichotomous data, users versus nonusers, limited the data analysis to a nonparametric design. Future studies should survey users to determine how many and which HESI Specialty Exams are administered so that the effect of administering multiple specialty exams may be investigated. This study explored the value of individual HESI Specialty Exams within the nursing curriculum as Table 4. Strategies Used to Implement HESI Specialty Exams Implementation strategies Number of schools Percent of schools As final exams 6 16.67 Practice 6 16.67 Remediation only 9 25.00 Other 15 41.66 Student self-assessment Knowledge of national ranking Course test grade Systematic curriculum evaluation Total respondents 36 100.00
IMPACT OF HESI SPECIALTY EXAMS S15 Table 5. E 2 Scores for HESI Specialty Exam Users by Implementation Strategy Specialty exam strategy Number of students E 2 mean score Statistical Findings SD SE df t test P Final exam 524 875.2 109.6 4.8 1,145 2.56.01 Practice/Remediation 868 859.5 112.5 3.8 Total 1,392 P b.01. measured by E 2 scores. Findings indicated that students who took these specialty exams during their curriculum scored significantly higher on the E 2 than those who did not take specialtyexams during their curriculum. Out of the eight HESI Specialty Exams that were investigated, Critical Care, Pediatrics, and Medical Surgical were the three most predictive of NCLEX-RN success. Findings indicated that those who scored 850 and higher on these specialty exams were more likely to pass the NCLEX-RN than those who scored lower than 850 11.16 times more likely for Critical Care, 5.51 times more likely for Pediatrics, and 5.50 times more likely for Medical Surgical. Conclusions The E 2 and HESI Specialty Exams are standardized exams that contain critical thinking test items and, as such, evaluate students' ability to apply content and concepts to clinical problems. Limitations such as curricular differences, varying faculty expertise, and students' individual experiences may have influenced the findings of this study. However, based on analyses of the data obtained, the E 2 can be confidently used to evaluate students' readiness for the NCLEX-RN, and HESI Specialty Exams can be used to objectively evaluate students' curricular achievements. Subject matter scores provided by these exams can serve as a guide to remediation to help prepare students for the licensure exam. HESI Specialty Exams help prepare students for the E 2, and administration of specialty exams throughout the nursing curriculum promotes early remediation that can help ensure students' success within the nursing program and ultimately on the licensure exam. When HESI Specialty Exams are administered as course final exams, students score higher on the E 2 than when specialty exams are used for practice and remediation only. Therefore, implementing HESI Specialty Exams as final exams helps improve students' E 2 scores, and the higher students score on the E 2, the more likely they are to succeed the first time they take the NCLEX- RN. Finally, the E 2 and HESI Specialty Exams provide quantitative evidence of faculty and curricular effectiveness so that they can be used as a measure of external curriculum evaluation. References Adamson, C., & Britt, R. (2009). Repeat testing with the HESI Exit Exam Sixth validity study. CIN: Computers, Informatics, Nursing, 27, 393 397. Bentley, R. (2006). Comparison of traditional and accelerated baccalaureate nursing graduates. Nurse Educator, 31, 79 83. Crocker, L., & Algina, J. (1986). Introduction to classical and modern test theory. Belmont, CA: Wadsworth/Thomson Learning. 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