DESIGN AND IMPLEMENTATION OF NURSING STUDENT CLINICAL EXPERIENCES AND PROGRAM EFFECTIVENESS AS MEASURED BY NCLEX-RN PASS RATES Martha L. Tanicala A Dissertation Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of Doctor of Education August 2006 Committee: Rachel A.Vannatta, Advisor Jennifer Z. Gillespie Graduate Faculty Representative Elizabeth J. Cain Eric D. Jones Patrick D. Pauken
ii ABSTRACT Rachel A.Vannatta, Advisor This study examined the characteristics of design and implementation of student clinical learning experiences and program effectiveness in baccalaureate nursing education programs in Indiana, Michigan and Ohio as measured by NCLEX-RN pass rates. Questions were asked to elicit information regarding clinical curricular design in the following areas: clinical hours, clinical sites, clinical categories, faculty characteristics, factors influencing curricular design, and clinical evaluation methods. The survey instrument Clinical Experiences in Baccalaureate Nursing Programs (CEBNP) was sent to the 56 baccalaureate nursing programs in Indiana, Michigan and Ohio. The questionnaire consisted of 80 items, most of which were fill in the blank or open-ended. Fifteen surveys were returned. The sample consisted of 14 institutions. The purpose of this study was to explore the relationship of curricula design and implementation of nursing student clinical experiences with NCLEX-RN pass rates in nursing education programs in Indiana, Michigan and Ohio. The data were analyzed using both descriptive and inferential methods. Descriptive techniques were used to summarize the data on the dependent variable of NCLEX-RN pass rates. Descriptive statistics of simple, grouped and cumulative frequency distributions were constructed to summarize the data and understand the characteristics of each nursing program. T- test of independent samples and ANOVA were used to assess group differences. Factor analysis was utilized to reduce the number of variables and to determine which variables and subscales clustered together. Pearson correlation was used to evaluate the relationship of NCLEX-RN
iii overall pass rate with several survey items and factors. A forward multiple regression was conducted to determine clinical program characteristics that best predict overall NCLEX-RN pass rates. Two statistically significant correlations were found. Clinical days per week in level one had a negative correlation with the overall pass rate for institutions in the sample. The number of long-term care clinical hours had a positive correlation with the overall pass rate for institutions in the sample. Multiple regression revealed no statistically significant predictors of NCLEX-RN pass rates. Public institutions had a statistically significantly lower overall pass rate than private institutions in the sample. Despite similar NCLEX-RN pass rates among the institutions in the sample, there was great variability in the design of clinical experiences. No specific structure was identified as best practice in the design and implementation of clinical curricula. Implications of these and other results are discussed in terms of influence on clinical curricula design in nursing education. Ideas for future research are also discussed.
iv This manuscript is dedicated to my mother and in memory of my father, Grace and Howard Ohm who were present throughout my dissertation process. Although my father died before I began my doctoral work, I felt his support and belief in my abilities, which enabled me to persevere and finally succeed.
v ACKNOWLEDGMENTS Special gratitude goes to my dissertation chairperson, Dr. Rachel Vannatta, who was patient and supportive of this old woman throughout the challenges and curves both in my personal life and the research process. I would never have completed this project without her words of encouragement and understanding when I kept asking during data analysis, are you sure we can do this?, and tell me the goal of transformation again? I would like to thank Dr. Patrick Pauken for his belief in my ability and continuously reminding me that someday I would be able to put a period on this manuscript. Thanks to a special friend and committee member, Betty who during our morning workouts and over coffee listened to my struggles and helped put into perspective my goal for world peace. I would also like to acknowledge all of my colleagues at Eastern Michigan University, especially Betty B., who kept asking how I was doing and April who shared similar dissertation emotions and Saturdays so my dissertation became a reality. Thanks to everyone, family and friends who always politely asked what is your topic and when will you be done? Now Christian, you can call me Dr. Nana, or simply Nana.
vi TABLE OF CONTENTS Page CHAPTER I: STATEMENT OF THE PROBLEM Introduction to the Problem... 1 Rationale for Conducting the Study... 4 Purpose... 5 Variables... 6 Definition of Terms... 7 Significance of the Study... 11 Research Questions... 12 Assumptions and Limitations... 12 CHAPTER II: REVIEW OF THE LITERATURE Significance of the Clinical Field in Nursing Education... 15 Clinical Practice in Nursing Education and Entry Level Nursing Competence... 17 NCLEX-RN as a Measure of Entry level Nursing Competence... 18 Predictors of NCLEX-RN Success... 19 Clinical Practice Component of the Curriculum... 24 Faculty Teaching Clinical Courses... 27 Summary... 29 CHAPTER III: METHODOLOGY Participants... 31 Design... 32 Instrumentation... 34
vii Data Collection and Analysis... 38 Limitations of the Study... 43 CHAPTER IV: RESEARCH FINDINGS Descriptive Results... 45 Inferential Results... 55 CHAPTER V: DISCUSSION AND CONCLUSION Summary and Discussion... 65 Recommendations and Implications... 70 Conclusions... 73 REFERENCES... 75 APPENDIX A QUESTIONNAIRE... 80 APPENDIX B CONSENT LETTER... 85 APPENDIX C LIST OF PARTICIPANTS... 87
viii LIST OF TABLES Tables Page 1 Independent Variables/Subscales... 35 2 Descriptives Research Question 1... 40 3 Inferential Statistical Methods Research Question 2... 42 4 Inferential Statistical Methods Research Question 3... 43 5 Characteristics of Institutions... 46 6 NCLEX-RN Pass Rates... 47 7 Clinical Hours by Clinical Area of Study... 48 8 Distribution of Clinical Hours... 49 9 Clinical Hours by Clinical Site... 50 10 Curricular Influences for Design and Implementation of Clinical Experiences... 51 11 Characteristics of Faculty Teaching Clinical Courses... 53 12 Group Differences and Transformed Overall Pass Rate... 56 13 Component Loadings Clinical Categories... 58 14 Component Loadings Distribution of Clinical Hours... 59 15 Component Loadings Clinical Sites... 60 16 Component Loadings of Faculty Characteristics... 61 17 Correlation Coefficients of Survey Items Used Separately with Overall Pass Rate.. 62 18 Correlation Coefficients of Factors with Overall Pass Rate... 63
1 CHAPTER I: STATEMENT OF THE PROBLEM Introduction to the Problem The aging of the American population, the market-driven economic policy related to health care delivery, and the nursing shortage are key issues currently influencing nursing education. The National Center for Health Statistics (NCHS) (1999) estimates that by the year 2030, 20% of Americans will be 65 years or more old. Another major health issue that supports the need for more health care professionals specifically registered nurses is the high incidence of chronic conditions such as arthritis, diabetes, and hypertension (National Center for Health Statistics [NCHS], 1999). Various lifestyle health problems such as those associated with obesity, smoking, and alcohol use increase the need for health care resources provided by qualified health professionals. More registered nurse positions remain open in both inpatient and outpatient healthcare settings. The need for registered nurses is estimated to increase in acute care settings by 36 % by the year 2020 (American Association of Colleges of Nursing [AACN], 2004). Increasing demand for registered nurses is rising at a faster pace than the supply can be met by nursing educational programs (AACN, 1998). The nursing shortage projection for the year 2015 is that there will be 114,000 unfilled registered nurse positions nationwide (AACN, 2004). Leaders in nursing education recognize that limited financial and human resources in nursing education programs nationwide are severely restricting student enrollments and limiting the ability of nursing education programs to meet the demand for registered nurses (AACN, 2004). Other factors contributing to the nursing shortage include insufficient increase in nursing student enrollment to meet the projected demand for nurses, shortage of nursing faculty, aging of the nursing population, increase in number of nurses leaving the profession and a need for more nurses to care for the aging population (AACN, 1998).
2 Educational preparation for professional nurses needs to reflect the current climate of health care and assist graduates in meeting the challenges of maintaining and promoting health in a cost effective coordinated care system to culturally diverse groups and underserved populations in various settings (AACN, 2004). As a practice discipline, it is essential that the design of nursing education programs assist students in developing the knowledge and skills necessary to be competent professional nurses. The increased complexity of the scope of professional nursing practice requires a workforce that is responsive to change and has experience in various clinical settings that reflect actual nursing practice. Aiken, Clarke, Cheung, Sloane and Silber (2003) found a direct correlation between the educational preparation of registered nurses and patient outcomes. Changes in health care delivery with an emphasis on health promotion requires nursing education programs to increase emphasis on diverse practice settings including community experiences. Clinical learning experiences in nursing courses with a clinical component in nursing education programs need to be designed based on the expanding scope of professional nursing practice. Program development including evaluation and outcome measurements should be based on the clinical practice of registered nurses nationwide. The Commission on Collegiate Education (CCNE), which is the accrediting body for colleges of nursing, requires baccalaureate nursing educational programs to provide clinical experiences for nursing students. One of the desired outcomes of the clinical experiences is to assist graduates in developing skills in interdisciplinary collaboration, case management, primary health care, health promotion and maintenance opportunities in acute and long-term care (AACN, 1999). One role of various accrediting bodies for nursing education including AACN, National League for Nursing Accrediting Commission (NLNAC) and state boards of nursing is to determine program
3 effectiveness through student outcomes. The pass rate on the National Council Licensure Examination- Registered Nurses (NCLEX-RN) is a program outcome that is measured by CCNE Standard IV as a part of program effectiveness (Standards for Accreditation of Baccalaureate and Graduate Nursing Programs, 2003). Nurse educators and leaders in health care agencies have a vested interest in nursing graduates performance on the NCLEX-RN. Passing the NCLEX-RN is the minimum standard for nursing practice and licensure. The National Council of State Boards of Nursing (NCSBN) conducts a nursing practice analysis study every three years. A stratified random sample of registered nurses who have been licensed within the last six months prior to the job analysis study are given the questionnaire. The results of this triennial survey are utilized to develop the NCLEX-RN blueprint that reflects nursing practice. Since yearly NCLEX-RN pass rates for nursing education programs are utilized as one program outcome by both nursing education accrediting bodies and state boards of nursing that grant approval of nursing education programs, it follows that review of program variables might assist in determining relationships to student outcomes. The identification of factors that influence and predict graduate performance on the NCLEX-RN has significance for both nursing students and educators. Determination of variables that predict graduate performance can assist educators in developing nursing curricula and providing academic and personal support and advisement services to support graduate success on the NCLEX-RN. Individualized study plans can be developed to assist graduates in preparing mentally, physically and emotionally for the challenges presented by the NCLEX-RN.
4 Rationale for Conducting the Study Recent NCLEX-RN data reflects a decrease in successful completion for first-time candidates (Daley, Kirkpatrick, Frazier, Chung & Moser, 2003). Historically students who have the largest number of clinical hours such as seen in diploma or hospital-based and associate degree nursing schools have the highest success rate on the licensing examination. Traditionally baccalaureate nursing education programs have more supportive academic courses in the liberal arts and didactic courses in the nursing curriculum and thus a smaller number of clinical hours. Supporting successful performance of graduates on the NCLEX-RN has additional value for schools of nursing, local communities and state boards of nursing. The evaluation process of nursing schools by various accrediting agencies and state boards of nursing utilize the NCLEX- RN pass rates as one measure of quality and effectiveness of nursing education programs. Nursing licensure enables graduates to practice as registered nurses. Potential students often assess the quality of a nursing school and likelihood of personal success in the nursing program based on NCLEX-RN pass rates and the amount and variety of clinical experiences in the program. In addition local communities depend on area nursing schools to provide quality health care professionals to assist in meeting the health needs of families in the community. Researchers have attempted to determine characteristics of nursing students that predict candidate performance on the NCLEX-RN ( Barkley, Rhodes & Dufour, 1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001). To date, most of the information used to predict graduate performance on the NCLEX-RN has been gathered retrospectively through student academic records that utilize student variables including admission criteria, grade point averages, grades earned in science courses, nursing school progression, standardized testing and exit data to predict performance on the NCLEX-RN (Morrison, 2002; Seldomridge & DiBartolo, 2004).
5 However, few studies have identified curricular factors, such as the design and implementation of student clinical practice learning environments as they relate to NCLEX-RN pass rates. Mozingo, Thomas and Brooks (1995) examined perceived competency levels of graduating seniors in a single baccalaureate nursing program. Implications for curricular modifications included the need to begin clinical experiences in the sophomore year and to design experiences that enhance the professional development of students and prepare them for practice (Mozingo, Thomas, & Brooks). Other researchers have used student exit data and graduate surveys to examine the relationship between clinical experiences and the opportunity to develop self competence in the nursing role and performance on the licensure examination. Results indicate that student performance in the final senior medical surgical clinical experience was a program variable that was a significant predictor of NCLEX-RN success in one baccalaureate nursing program (Daley, Kirkpatrick, Frazier, Chung & Moser, 2003). As a practice discipline, it is essential that the practice component in nursing education programs be designed, implemented and evaluated in a manner that reflects current nursing practice and prepares the graduate for entry level nursing competence. For such a discipline that uses a practice based licensing examination to determine competence, the practice component of nursing education is an important variable to examine for its relationship to student performance on the NCLEX-RN and entry level nursing competence. Characteristics of clinical curricula design of 14 baccalaureate nursing education programs in Indiana, Michigan and Ohio were identified and compared in respect to NCLEX-RN pass rates from 2002-2004. Purpose The purpose of this study was to explore the relationship of curricula design and implementation of nursing student clinical experiences with NCLEX-RN pass rates in the
6 baccalaureate nursing education programs in Indiana, Michigan and Ohio. The accessible population consisted of the 22 baccalaureate nursing education programs in Indiana, the 17 baccalaureate nursing education programs in Michigan and the 22 baccalaureate nursing education programs in Ohio. Of the 61 institutions, only 15 responded. Data were collected using a survey that gathered information from nursing education administrators concerning design of clinical practice in their baccalaureate nursing education programs which are located in Indiana, Michigan and Ohio. The Clinical Experiences in Baccalaureate Nursing Programs (CEBNP) survey consisted of questions regarding the design, implementation and evaluation of clinical courses including the types and amount of clinical learning experiences. Variables assessed regarding the design of clinical practice experiences included: number of clinical hours in each course with a clinical component, total program clinical hours, practice settings for clinical experiences, types of acute care and community settings, courses with clinical experiences, number of years in program with clinical experiences, clinical faculty characteristics, clinical evaluation as well as grading policies, and clinical practicum or capstone course at the end of program. Nursing education experts were consulted to provide input in developing the survey instrument and in the determination of the variables that have the greatest influence on clinical practice experiences. All data were analyzed using the Statistical Package for the Social Sciences (SPSS-PC Version 12.0). Variables Dependent Variable The dependent variable in this study was NCLEX-RN pass rates in baccalaureate nursing education programs in Indiana, Michigan and Ohio. NCLEX-RN refers to the National Council Licensure Examination for Registered Nurses. Successful performance on this examination
7 indicates minimum entry level competence as a registered nurse and enables the candidate to obtain a nursing license to practice nursing in the state the licensure application was submitted. The NCLEX-RN pass rate was a percent based on the number of successful first-time candidates divided by the total number of first-time candidates taking the examination during a calendar year. The pass rate is calculated annually by the state board of nursing for each nursing education program in the state. Independent Variables The CEBNP survey measured several subscales that served as independent variables for the study: clinical categories (items 5-15), clinical hours (items 4, 16-20, 22, 24, 26) clinical sites (items 27-33), factors that influence the design of clinical experiences (items 34-48), characteristics of faculty teaching clinical courses (items 49-65), and evaluation of student clinical performance (items 66-73). Factor analysis was used to create factors within each subscale. Definition of Terms The dependent and independent variables and the following terms were used throughout the study and were defined as follows. Clinical Practice Learning Environment: Conceptual Definition For this study, clinical practice learning environment was defined as any agency, health care facility, nursing skills laboratory, or planned clinical practice setting that provided learning opportunities for nursing students in baccalaureate nursing education that were appropriate for contemporary nursing.
8 Hours of Clinical Experiences: Conceptual Definition Information regarding the number of hours of clinical experiences were gathered in terms of the number of clock hours nursing students spend per day, per week, per clinical course and total in nursing program in clinical practice learning environments. Factors that Influence the Design of Clinical experiences: Conceptual Definition The significance of curricular, legal, administrative, financial and clinical practice factors that are part of the decision making process utilized to design, implement and revise clinical learning experiences were assessed and ranked in the survey instrument in regard to degree of influence. The specific factors assessed were: yearly course evaluations, accreditation standards and recommendations, standardized testing results of students, student feedback, clinical agency feedback, clinical faculty feedback, changes in nursing practice, administrators in the school of nursing, availability of clinical sites, availability of human and financial resources, state board of nursing rules and regulations, NCLEX-RN test plan and NCLEX-RN pass rates. Faculty Teaching Clinical Courses Faculty teaching clinical courses was defined as the faculty of record who teach the specific clinical course or clinical portion of the nursing course with a clinical component. The faculty teaching clinical courses assume responsibility for evaluation of student clinical performance and ultimately assign the final grade. Evaluation of Student Clinical Performance Evaluation of student clinical performance involved the specific method of determining the final grade or student clinical competence in each clinical course and/or the clinical component of each nursing course.
9 Clinical Course Clinical Course is defined in Chapter 4723 of the Ohio Administrative Code (2003) as a nursing course that includes clinical experience. The clinical component provides students with opportunities and learning experiences to incorporate nursing theory into practice. Clinical Experience Clinical experience is defined in Chapter 4723 of the Ohio Administrative Code (2003) as an activity planned to meet course objectives or outcomes and to provide a nursing student with the opportunity to practice cognitive, psychomotor, and affective skills in the delivery of nursing care to an individual or group of individuals. Indiana State Board of Nursing defines clinical experience as the learning experiences provided in facilities appropriate to the curriculum objectives which prepare graduates to practice nursing as a licensed registerd nurse (848 Indiana Administrative Code (IAC), 1-1-2-1, 2005). In accordance with the Michigan rules and regulations governing nursing education clinical experience is defined as direct nursing care experiences with patients or clients which offer students the opportunity to integrate, apply and refine specific skills and abilities which are based on theoretical concepts and scientific principles (Administrative Rules of the Michigan Board of Nursing, R 338.10301, 2003).The Administrative Rules of the Michigan Board of Nursing (2005) require a core curriculum in registered nurse education programs to include courses in planned clinical learning (p.3) in each of the following five areas of nursing: medical, obstetrical, pediatric, psychiatric and surgical and must include nursing care of persons throughout the lifespan. Faculty Teaching Clinical Courses Faculty teaching clinical courses referred to those individuals who teach the practice component in the clinical courses. The term clinical instructor was also used to refer to the
10 individual who was responsible for the practice component in clinical courses. Faculty teaching clinical courses may be the same individuals or different individuals than those who teach the didactic portion in the nursing courses. Direct Clinical Experience Direct clinical experience indicated that the nursing student was directly involved and responsible for performing cognitive, psychomotor and affective skills in the delivery of nursing care to an individual or group of individuals as defined by the scope of practice as a registered nurse. Laboratory Experience Laboratory experience was an activity planned to meet course objectives or outcomes and to provide a nursing student with the opportunity to practice cognitive, psychomotor, and affective skills in the performance of nursing activities or tasks. The experience may be provided in any setting including, but not limited to, a learning resource center, an acute care or long term care facility, and a community setting (Chapter 4723 Ohio Administrative Code, 2003). The Michigan Board of Nursing defines clinical laboratory hours as those hours that simulate learning, provide opportunity for laboratory practice and provide observational experiences that enable the student to meet educational objectives. Observational Clinical Experience Observational clinical experience was an activity in which the nursing student did not accept an active role or accept responsibility for the performance of nursing activities or tasks performed by a registered nurse. The role of the student is to observe a registered nurse perform cognitive, psychomotor, and affective skills in the performance of nursing activities and tasks.
11 Preceptor Preceptor in accordance with Chapter 4723 of the Ohio Administrative Code (2003) was defined as a licensed nurse who provides supervision of a nursing student s clinical experience at the clinical agency in which the preceptor is employed, to no more than one student at any one time, and who implements the clinical education plan at the direction of a faculty member participating in the course in which the student is enrolled. Clinical preceptor is an individual that is employed by the cooperating agency who also has the responsibility to supervise one student at a time in the clinical facility (IAC, 1-1-2-1. 2005). Program Program was defined as prelicensure nursing education program that includes, but is not limited to associate degree, baccalaureate degree, diploma, or certificate in professional nursing leading to initial licensure to practice nursing as a registered nurse (Chapter 4723-5-01, 2003). Indiana Administrative Code (2005) defines a baccalaureate degree program as an educational program which leads to a baccalaureate degree in nursing where the educational nursing component is conducted within the structure of a senior college or university. Significance of the Study The purpose of this study was to explore the relationship of clinical curricula and NCLEX-RN pass rates in baccalaureate nursing education programs in Indiana, Michigan and Ohio. Stakeholders that benefit from this study include nursing students, nursing education programs, nursing practice settings and employers of registered nurses, state boards of nursing, professional accrediting bodies and health care consumers. As a professional discipline, the practice component in the education process is where the student learns to think and act like the professional in the nursing discipline (Reilly & Oermann, 1985). Employers of registered nurses
12 in various practice settings have identified critical thinking, clinical decision-making skills and therapeutic relationship skills as the most important skills for registered nurse practice and essential in making hiring decisions (National Council of State Boards of Nursing [NCSBN], 2005). Health care agencies expect nursing graduates to apply the knowledge and skills gained in the nursing clinical courses to the practice setting upon successfully completing the NCLEX-RN. Nursing students are given opportunity to develop these skills in clinical practice experiences provided as part of the clinical courses in nursing education programs. Nursing educators can utilize the information gained from this study to design and implement clinical courses in accordance with best practice guidelines as a means of increasing NCLEX-RN pass rates. Research Questions The following research questions were addressed in this study: 1. What were the characteristics of clinical practice learning environments in baccalaureate nursing education programs in Indiana, Michigan and Ohio? 2. Do pass rates in nursing programs significantly differ by groups as defined by the following variables: clinical and theory combined as one course, clinical component graded separately from the nursing theory, clinical practicum/capstone course, location of institution, public or private sponsorship, and number of students in the school of nursing. 3. To what degree did the design and implementation characteristics of clinical practice learning experiences predict NCLEX-RN success for first-time candidates? Assumptions and Limitations Three underlying assumptions in this study were: 1) clinical practice is included in all baccalaureate nursing education programs 2) student clinical experience is a key component in determining entry level competency as a registered nurse, and 3) curricular design affects student
13 success. A limitation of this study was that many factors that influence the dependent variable of NCLEX-RN pass were not examined. Information concerning specific characteristics of nursing students including the identification of high risk students who might be foreign born students or students with low grade point averages was not sought in the survey. Student information regarding preparation for the NCLEX-RN was not gathered. Information regarding financial resources of nursing education programs was not gathered. Admission criteria, progression policies, attrition rates and graduation rates for each nursing program were not considered in this study. Research already existed to support the influence of the above policies and program variables in predicting student success on NCLEX-RN (Haas, Nugent, & Rule, 2004; Morrison, Free & Newman, 2003; Washington & Perkel, 2001). Little research was available that explored and explained the relationship of the program variables of clinical practice experiences in nursing education and NCLEX-RN pass rates. The assumption in this study was that the process of curriculum design of clinical courses can be done in a manner that supports NCLEX-RN success for nursing graduates. The sample itself was also a study limitation. The sample was limited to one geographical location of three Midwestern states. Clinical design characteristics of baccalaureate nursing education programs in Indiana, Michigan and Ohio may not be representative of institutions in other geographic locations. The poor response rate, 14 of 56, limited generalizability and the ability to determine any relationship of clinical learning experiences and NCLEX-RN pass rates. The following chapters address the significance of the clinical practice component in nursing education and the methodology and results of the research study. The review of the literature in Chapter II provides support of clinical practice in nursing education and the role of NCLEX-RN as a measure of entry level nursing competence. The design of the study, variables
14 included in the study, research questions addressed in the study and the methods employed to carry out the research are discussed in Chapter III. Chapter IV presents both the descriptive and inferential results of the research study. A summary and discussion of the results and recommendations for further research are presented in Chapter V.
15 CHAPTER II: REVIEW OF THE LITERATURE Education of health care professionals has moved from an apprenticeship model in the first half of the twentieth century to an academic environment that involves both liberal and discipline specific education which includes clinical field practice experience (Dunn, Ehrich, Mylonas & Hansford, 2000). The clinical practice component in nursing education will be reviewed in its total spectrum regarding significance of the clinical field in nursing education; clinical practice in nursing education and entry level nursing competence; role of NCLEX-RN as a measure of entry level nursing competence; predictors of NCLEX-RN success; framework of the clinical field; characteristics of faculty teaching clinical courses; and trends in nursing and health care and educational outcomes. Review of the literature supports the importance of the clinical practice component in nursing education programs. Significance of the Clinical Field in Nursing Education The clinical field provides students the opportunity to experience the complexity of the human interaction and response embedded in the nursing profession that is not possible in the classroom setting. Students are given opportunity to develop clinical judgment and utilize knowledge in the contextual whole of the learning experience (Bevis & Watson, 1989). Reilly and Oermann (1985) state that clinical practice in a professional program extends beyond the general purpose of providing opportunity to apply theory to practice with real patients in real life settings. The emphasis is on the development of competencies of the professional person who is capable and practices in a manner that supports responsibility and accountability in a dynamic diverse society within complex health systems (Reilly & Oermann). Clinical education promotes student learning encounters with the artistic aspects of nursing and assists students in making meaningful relationships, see patterns and gain new insights which are limited in structured,
16 controlled classroom environments (Bevis & Watson, 1989, Reilly & Oermann). Students are able to observe and interact with nurses as they practice the art of nursing and serve as role models in various stages of development and nursing expertise. Benner (1984) contends that knowledge is discovered and embedded in actual nursing clinical practice and supports a situation based approach to learning. Situation based learning strategies such as provided in clinical practice learning environments assists in explaining the differences in clinical performance and the growth and development of nursing competence. Billings and Halstead (1998) state the purpose of the clinical component of nursing education as one of the means in which students can use newly acquired knowledge and skills, think critically, make clinical decisions, and acquire professional values necessary to work in the nursing profession (p. 281). According to Reilly and Oermann (1985) the purpose of clinical practice in an educational program includes assisting students in learning how to learn, dealing with ambiguity, and thinking like professionals and developing the commitment to accept personal responsibility for one s own actions and behavior. Reilly and Oermann (1985) utilize the theoretical framework of Argris and Schon (1974) to assist in understanding the purpose of the clinical practice component in nursing education. Foundational elements of this action theory are based on the assumption that specific practice situations will yield intended student outcomes and that learning is enhanced and more effective when the student is engaged and assumes the role of active participant (Reilly & Oermann). Knowledge is applied in context during each student clinical experience. Viewing the clinical practice setting as a learning experience implies active involvement of the student as the nursing student experiences the practice of nursing (Reilly & Oermann, 1985). This concept of learning and behavioral change is explained by Hergenhahn (as cited in
17 Reilly & Oermann) who contends that experience leads to learning and then in turn results in a change in behavior. Learning through the experience involves a change of behavior from that of nursing student to the desired educational outcome as the student thinks and performs like a nurse. Dewey (as cited in Reilly & Oermann) believes the essence of this lived experience is to prepare the learner for more complex situations that is typical in the practice of nursing. Included in the lived experience of the nursing student in clinical practice settings is the opportunity to observe nurses actively engaged in nursing practice. Nurses and clinical nursing faculty serve as role models for nursing students during clinical learning experiences. Role modeling is an effective teaching/learning strategy that is a significant part of the clinical learning experience for students. Clinical Practice in Nursing Education and Entry Level Nursing Competence Links between nursing education, nursing service and health care are continuing to grow and shape the knowledge and skills required for entry level competence. Lindeman (2001) explores the future of nursing education in the context of the changes and trends in health care and the scope of nursing practice. Nurses practice in a variety of clinical settings including acute care facilities, long term care and rehabilitation organizations, and outpatient and community agencies. Desired educational objectives for clinical education in the above clinical practice settings includes a broad knowledge base, critical thinking, life-long learning skills and specific employment skills of technical clinical competence and work organizational skills (Dunn, Ehrich, Mylonas & Hansford, 2000). King, Smith and Glen (2003) conducted a research study to determine entry level competencies needed by bachelor in science of nursing (BSN) graduates in acute health care facilities. Health care agencies and faculty in BSN programs were surveyed regarding 24 entry level competencies needed by BSN graduates in the next ten years. The
18 technical skill of administration of intravenous (IV) medications to assigned patients, participation in quality improvement monitoring process, utilization of cost-effective care, and assumption of responsibility and accountability for patient satisfaction were competencies that were ranked as very important by nurses in acute health care agencies and recent BSN graduates (King, Smith & Glenn, 2003). Nursing students need opportunity in clinical practice learning environments to develop these entry level skills. Recommendations for BSN nursing education from this study included developing teaching strategies to support critical thinking, possible need for a critical care track, and establishing a collaborative partnership between service agencies and nursing faculty to discuss curriculum design based on health care trends affecting nursing practice (King, Smith & Glenn). NCLEX-RN as a Measure of Entry Level Nursing Competence Performance on NCLEX-RN, a practice-based exam, is one measure of entry level competence in nursing. Every three years the National Council of State Boards of Nursing (NCSBN) conducts a nationwide study of newly licensed registered nurses to gain information of specific nursing activities and skills performed by registered nurses at the entry level. This information is then utilized to outline the relationship between nursing practice and the licensure examination and ultimately directs the content and scope of nursing practice on the licensure examination (Wendt, 2003). Successful performance on the NCLEX-RN is one of the educational outcomes that indicates a graduate has the necessary knowledge, skills, abilities and competencies required to practice nursing (Wendt). The NCLEX-RN test plan that has been developed to reflect entry level nursing practice is often utilized by nurse educators as a framework for curriculum design including both didactic and clinical instruction. The current test plan for the National Council Licensure Examination for
19 registered nurses, effective date April 2004, was developed based on the review of the results of the 2002 RN practice analysis as part of the triennial evaluation of NCLEX-RN. The test plan is the blueprint for the NCLEX-RN. The examination committee and the National Council of State Boards of Nursing (NCSBN) collaborate to develop an exam that is job-related and is reflective of the knowledge and skills utilized by nursing graduates during their first six months following licensure as an RN (NCSBN, NCLEX Examinations Test Plan, 2003). A practice analysis is used to gather data that reflects current nursing practice of the entry level nurse (Smith & Crawford, 2003). The 2002 practice analysis that is designed to link the nursing licensing exam to nursing practice gathered data from more than 4,000 newly licensed nurses (Smith & Crawford, 2003). Information was obtained regarding the frequency and priority of more than 130 nursing care activities that relate to maintaining patient safety and the specific patient care settings or clinical sites where the activities were performed (Smith & Crawford). The results of this analysis serves as a guide for determining the skills and knowledge necessary for entry level practice which is then utilized to develop the NCLEX-RN examination as a practice-based examination. Predictors of NCLEX-RN Success Predicting whether a student will be successful on the NCLEX-RN has been an important topic in nursing education research for the past two decades. The focus of such research has explored both academic and nonacademic variables. Academic and Nonacademic Variables Variables such as grade point average (GPA), science grades, nursing course grades, scores on standardized testing including Scholastic Aptitude Test (SAT) or American College Testing (ACT), National League for Nursing (NLN) achievement test scores, and exit tests such
20 as the Mosby Assess Test have been linked to student success on the NCLEX-RN (Barkley, Rhodes & Dufour, 1998; Crow, Handley, Morrison, & Shelton, 2004; Daley, Kirkpatrick, Frazier, Misook, Chung & Moser, 2003; Haas, Nugent, & Rule, 2004; Seldomridge & DiBartolo, 2004). As early as 1998, Barkley, Rhodes and Dufour found a link to student success on NCLEX-RN and nursing clinical course grades. Records of 81 students in one baccalaureate nursing program were reviewed. Barkley, Rhodes and Dufour (1998) found a positive correlation with nursing theory and clinical courses and performance on NCLEX-RN. Probability of failure on NCLEX-RN was found to increase when a student earned a letter grade of C either in a nursing clinical course or nursing theory course (Barkley, Rhodes & Dufour). Arathuzik and Eber (1998) conducted a descriptive-correlational study to determine factors associated with NCLEX-RN success. The study explored both academic and nonacademic variables including internal and external blocks that made it difficult for student to focus on nursing studies and prepare for the licensing examination. A convenience sample of 79 senior nursing students who were one month away from graduation was used in their study. Significant correlations were found between the dependent variable of NCLEX-RN success and cumulative nursing program grade point average and sense of competency in critical thinking. Self-efficacy and competency in critical thinking are directly linked to student clinical experiences (Oermann & Reilly, 1998, AACN, 2003). Nursing Courses as Predictors Literature concerning the significance of program variables, specifically the effect of nursing courses in the curricula of nursing education programs that predict NCLEX-RN performance is limited. Beeman and Waterhouse (2001) utilized discriminant analysis in a retrospective study to identify the significance of 21 variables in predicting NCLEX-RN success
21 in a baccalaureate nursing program. A convenience sample of 289 nursing students who graduated from a baccalaureate nursing program between the years 1995 and 1998 was utilized in this study. Included in the 21 variables were SAT scores, grades of four science courses, gender, age, type of program (accelerated or traditional), eight didactic nursing courses, number of C+ or lower grades in nursing didactic courses, number of B or lower grades received in clinical courses and GPA measured at two points in the nursing program. Seven of the 21 variables were found to be significant variables and included the grades earned in nursing theory and clinical courses. The best predictor was the total number of C+ or lower grades in nursing theory courses. Grades in one of the clinical courses had the second highest discriminant function in predicting NCLEX-RN success. Another retrospective study was conducted by Beeson and Kissling (2001) to identify predictors of success for baccalaureate graduates on NCLEX-RN. Five hundred and five participants who graduated in the years 1993-1998 were selected from a baccalaureate nursing program in the southeastern United States. Variables that were identified as predictors included type of student, gender, age for the licensing exam, performance on selected prenursing courses including basic sciences and social sciences, cumulative grade point average at graduation and the Mosby AssessTest score. A logistic regression model was created that was significant in predicting 76 % of the students who failed based on the student information by the end of the first semester in the senior year. The probability of failure was found to increase for student who had an increasing number of C s in nursing courses. The stepwise variable selection method identified that the number of C s, D s and F s in nursing courses through the junior year and the Mosby AssessTest scores from the end of the senior year, and age group of traditional versus nontraditional were the best combination of variables for prediction. In response to this data, this
22 baccalaureate program utilized the clinical capstone course and specific clinical placements to assist in broadening the student s knowledge base and to strengthen the areas of weakness in clinical practice as an effective intervention to support the student s success on NCLEX-RN. This strategy supports the relationship and value of clinical practice in nursing education and demonstrating entry level competence as measured by NCLEX-RN. Waterhouse and Beeman (2003), as part of their ongoing research to identify variables that predict NCLEX-RN success modified the risk appraisal instrument (RAI) designed by Barkley, Rhodes and Dufour (1998) to collect data from student records on 538 individuals who graduated from a baccalaureate nursing program from 1995-1998. This new instrument, the Delaware Risk Appraisal Instrument (DRAI), substituted grades from program specific didactic nursing courses; pathophysiology; wellness nursing course; the number of C+ or lower nursing theory grades and the number of B or lower nursing clinical grades. Frequency distributions and correlations with NCLEX-RN success were determined. The DRAI was less effective in predicting success and more accurate in predicting failure on NCLEX-RN. The grades earned in the advanced medical surgical nursing or critical care nursing course was able to predict 78.4 % of the failures and 61.6 % of the passes and thus had an overall accuracy rate of 65.7%. Research continues to support that student grades in nursing courses have a direct relationship to NCLEX-RN success and pass rates in schools of nursing. Daley, Kirkpatrick, Frazier, Chung, and Moser (2003) evaluated student demographics, nursing program variables (including grades in two physical science course, one social science course and three nursing program courses), and the two standardized examinations (Mosby Assess Test and the Health Education Systems, Incorporated (HESI) Exit examinations) to identify predictors of graduate performance on NCLEX-RN. One of the nursing program courses included in the study was the
23 clinical senior medical-surgical course. This nursing course involves an intensive clinical experience caring for adults with acute and chronic multiple system illnesses and is six credit hours. Final grades for the physical science courses, both the didactic and clinical medicalsurgical nursing courses and cumulative program GPA were found to be significantly different between students who were successful and those who were unsuccessful on the NCLEX-RN. Crow, Handley, Morrison and Shelton (2004) conducted a national descriptive correlational study to determine the best predictors of NCLEX-RN success of graduates in baccalaureate nursing programs. Clinical proficiency was one of the findings that were determined to be significant in predicting success on NCLEX-RN. Student participants were recruited from the 513 generic baccalaureate nursing programs as listed in the National League for Nursing (NLN) official guide to undergraduate and graduate nursing schools as of the year 2000. The survey instrument was developed by the investigators. The first research question that was answered was related to the characteristics of admission, progression and graduation requirements used by baccalaureate nursing programs. Graduation requirement items included total credit hours, overall GPA, requirement of an exit exam, participation in NCLEX review and whether students needed to demonstrate clinical proficiency. Calculation of a Mantel-Haensel common odds ratio for the value of clinical proficiency and commercial NCLEX-RN review negated the significance that was found in the chi square test. This finding is inconsistent with relationship to commercial NCLEX-RN reviews and increase success on the licensure examination that has been found in a previous study by O Neal (1991) as cited in Crow, Handley, Morrison, and Shelton (2004). Little information was gathered related to student clinical performance or the clinical component of baccalaureate nursing programs.
24 In a retrospective descriptive study conducted by Seldomridge and DiBartolo (2004) at a rural, public baccalaureate nursing program, logistic regression was utilized to determine academic variables that best predict NCLEX-RN success and failure. Data from 186 students was gathered from 1998 to 2002. Ninety-four and seven-tenths of the NCLEX-RN passes and 33.3 percent of the NCLEX-RN failures were predicted by test average in advanced medicalsurgical nursing and percentile score on the National League for Nursing Comprehensive Achievement Test for Baccalaureate Students (NLN-CATBS). The combination of the variables of the NLN-CATBS and pathophysiology grade predicted 93.3 percent of NCLEX-RN passes and 50 percent of the failures. Failures on the NCLEX-RN were much more difficult to predict than successes. Specific information regarding the clinical component of the nursing program was not part of the thirteen independent variables that were selected as predictors. Despite the wealth of literature that supports the significance of the clinical component in nursing education programs, few research studies are available that examine the link of clinical practice in education to NCLEX-RN pass rates. Previous studies examine student variables and not program variables. What if any effects the specific program variable, total clinical curriculum, has on NCLEX-RN pass rates has not been studied. Clinical Practice Component of the Curriculum The Indiana, Michigan and Ohio Boards of Nursing prescribe standards and approve curricula in nursing education programs. The objectives of program approval include: 1. provide standards for legally recognizing new and established programs, 2. promote the safe practice of nursing by ensuring that new and established nursing education programs, preparing beginning level practitioners, meet and maintain established minimum academic and clinical practice standards; 3. provide assurance to graduates of approved nursing education programs