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Use of Aptitude to Understand Bachelor of Science in Nursing Student Attrition and Readiness for the National Council Licensure Examination-Registered Nurse
USE OF APTITUDE TO UNDERSTAND BACHELOR OF SCIENCE IN NURSING STUDENT ATTRITION AND READINESS FOR THE NATIONAL COUNCIL LICENSURE EXAMINATION-REGISTERED NURSE SARAH E. NEWTON, PHD, RN,*
AND
GARY MOORE, PHD, RN*
Attrition is a serious issue among Bachelor of Science in Nursing (BSN) students with attrition rates around 50% nationwide. To help minimize BSN student attrition, many nursing programs use commercially available standardized nursing aptitude tests as adjuncts to scholastic aptitude data, usually operationalized as pre-nursing grade point average, to select students for admission. Little is known regarding the usefulness of scholastic and nursing aptitude data for predicting long-term retention in a BSN program and readiness for the National Council Licensure Examination-Registered Nurse (NCLEX-RN). Therefore, the purpose of this study was to describe the relationships among scholastic aptitude, nursing aptitude, BSN student attrition prior to the final semester of the curriculum, and BSN student readiness for the NCLEX-RN. This study's findings, along with other findings in the literature, suggest the need for a parsimonious explanatory model of BSN student attrition that can be used to guide admission and progression policies, and ensure that students ready for the NCLEX-RN are the ones graduating from BSN programs. (Index words: Aptitude; Student attrition; NCLEX-RN, Undergraduate nursing) J Prof Nurs 25:273–278, 2009. © 2009 Elsevier Inc. All rights reserved.
A
PTITUDE IS THE complexity of knowledge needed by today's nursing students and can be broken down into nursing and scholastic aptitude. Nursing aptitude is more specific knowledge than scholastic aptitude and can be operationalized as college-level competencies in English, math, science, and reading comprehension (Newton, Smith, & Moore, 2007). Because baccalaureate nursing (BSN) curricula are academically rigorous, the literature indicates that BSN students who are admitted with strong scholastic and nursing aptitudes are less likely than students admitted
*Associate Professor, Oakland University, Rochester, MI. Address correspondence to Dr. Newton: Associate Professor, Oakland University, 448 O'Dowd Hall, Rochester, MI 48309. E-mail: [email protected] 8755-7223/$ - see front matter
with weak aptitudes to have progression/retention issues (Brown & Marshall, 2008; Gardner, 2005; Newton et al., 2007; Peter, 2005; Symes, Tart, & Travis, 2005). BSN student attrition can be curtailed when nursing program admission practices select applicants with high scholastic and nursing aptitudes (DiBartolo & Seldomridge, 2005; Newton et al., 2007; Stuenkel, 2006), but successful progression through the curriculum does not necessarily guarantee student readiness for the National Council Licensure Examination-Registered Nurse (NCLEX-RN). Nationwide, many BSN programs use commercially available standardized nursing aptitude tests along with scholastic aptitude to select candidates for admission to the nursing major (Assessment Technologies Institute [ATI], 2007b; Newton et al., 2007; Newton, Smith, Moore, & Magnan, 2007; Stuenkel, 2006). However, little empirical data exist that describes whether long-term retention in a BSN program
Journal of Professional Nursing, Vol 25, No 5 (September–October), 2009: pp 273–278 © 2009 Elsevier Inc. All rights reserved.
273 doi:10.1016/j.profnurs.2009.01.016
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and readiness for the NCLEX-RN can be predicted using student aptitude data. The purposes of this study were (a) to describe the relationships among prenursing scholastic aptitude, nursing aptitude, and student attrition prior to the final semester of a BSN program and (b) to assess the relationships among prenursing scholastic aptitude, nursing aptitude, and scores attained on a pre-NCLEX-RN assessment used to gauge senior students' readiness for the NCLEX-RN.
Literature Review Attrition among nursing students is a serious problem. Attrition is usually defined as “departure from a nursing program without successful completion of the program; but also can be defined to include students who are delayed in their progress toward program completion” (California Postsecondary Education Commission [CPEC], 2003, p. 12). Although the National League for Nursing Accrediting Commission suggests 80% as an acceptable retention rate for BSN programs, graduation rates for BSN programs are less than 50% nationwide (Brown & Marshall, 2008; Peter, 2005). High rates of attrition from nursing programs have been attributed primarily to the admission of minimally qualified students, specifically those not sufficiently prepared academically to begin the nursing major (Brown & Marshall, 2008; CPEC, 2003; Gardner, 2005; Newton, 2008; Newton et al., 2007; Symes et al., 2005). The literature indicates that BSN programs with more stringent admission policies may effectively “weed out” students who would otherwise be unsuccessful during the nursing major or fail the NCLEXRN (DiBartolo & Seldomridge, 2005; Newton et al., 2007; Stuenkel, 2006). However, even with more stringent admission policies, students who only minimally meet admission criteria often have academic difficulties after starting the nursing program (CPEC, 2003; Newton et al., 2007; Stuenkel, 2006). Preparedness for the nursing major can be evidenced in a number of ways (Stuenkel, 2006), but Seldomridge and DiBartolo (2004) believe that assessing the number of individual pre-nursing course grades a student has that are less than 2.5, not just overall pre-nursing grade point average (GPA), is potentially predictive of NCLEX-RN success. Similarly, Newton et al. (2007) reported that a rolling admission policy that facilitated large numbers of students being admitted to the nursing major contributed to issues with attrition following the first semester of the nursing curriculum. Students in the study by Newton et al. (2007) were admitted to either a Fall or a Winter cohort at one BSN program. Among the Fall cohort, 32 students (31%) had at least one prenursing course grade less than 2.5, whereas the Winter cohort had 48 students (63 %) with at least one prenursing grade less than 2.5. Newton et al. (2007) found that after the first semester of the nursing major, the attrition rates differed between the two cohorts. The Fall cohort had an attrition rate of 2% (2/103); the Winter cohort's attrition rate was 10% (7/ 70). The results of the study by Newton et al. (2007)
indicated that students with prenursing grades less than 2.5 contribute to program attrition. According to Gardner (2005), students who have a greater allegiance to an institution are likely to have better retention and graduation rates and that student retention is related to students being integrated into the social and intellectual life of the university. Gardner believes that students who are less integrated experience a lack of interaction and feel isolated from the daily life of the institution. Further, student failure to establish significant personal ties to the institution strongly affects their willingness to persist at the institution and is thought to be a large factor affecting the retention of students in higher education (Brown & Marshall, 2008; Gardner, 2005). One variable that may contribute to lack of integration among BSN students is transferring to the nursing program after starting one's post-secondary education at a community college (Newton, 2008). In a review of the literature, Newton addressed the potential impact community college transfer may have on BSN student retention. The literature identified that the milieu of community colleges tends to be student centered and designed to raise self-esteem (Townsend, 1995). Newton suggests that BSN students who initiate their postsecondary educations at community colleges are potentially at higher risk for attrition than students who initiate their post-secondary educations at a 4-year college or university. In order for BSN programs to identify the best predictors of academic achievement and to facilitate retention efforts, standardized nursing aptitude tests have been suggested as possible adjuncts to other available admission data (Crow, Handley, Morrison, & Shelton, 2004; Newton, Smith, Moore, et al., 2007; Stuenkel, 2006). One such test, the Test of Essential Academic Skills (TEAS) from ATI, can be used as part of the selection process for admitting students into post-secondary education programs (ATI, 2007b). The TEAS consists of four content areas: math, reading, English, and science (ATI). According to ATI, the TEAS was designed to predict those candidates with the highest likelihood of academic success prior to admission to a program of study in nursing. A study by Newton, Smith, Moore, et al. (2007) reported that the TEAS was able to predict first semester nursing program success. In addition, for sophomore students at risk of failure (operationalized as the number of pre-nursing course grades less than 2.5), the TEAS was a more reliable predictor of first semester success than was pre-nursing GPA. Newton, Smith, Moore, et al. (2007) concluded that early academic achievement depends on BSN programs admitting academically strong candidates into the program and that the TEAS provides additional data about students' core knowledge beyond that provided by pre-nursing GPA alone. Overcoming academic deficiencies is difficult for most students (Potolsky, Cohen, & Saylor, 2003), and students who are academically ill-prepared for the rigors of a BSN curriculum do not benefit emotionally or financially by
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being admitted and then failing during the program. Symes et al. (2005) discussed the need for successful retention programs for nursing students who, despite high GPAs in prerequisite courses, may encounter academic difficulties in BSN programs. Symes et al. described one such retention program, the Nursing Success Program (NSP), which was implemented for high-risk nursing students at Texas Woman's UniversityHouston Center. Students were identified as high risk based on the reading scores they obtained on the Nurse Entrance Test (NET), a scholastic aptitude test manufactured by Educational Resources, Inc. Symes et al. decided to use the reading comprehension scores as the advisement tool based on preliminary findings, suggesting that low NET reading comprehension scores were associated with higher rates of attrition. Prior to implementing the NSP, graduation rates for students with low reading comprehension scores were less than 50%. After the NSP was initiated, the high-risk nursing students had graduation rates similar to those students not assessed as highrisk (81%, respectively; Symes et al., 2005). Even when BSN students are successful in graduating from a nursing program, they are still, potentially, at high risk of failing the NCLEX-RN (Seldomridge & DiBartolo, 2004; Stuenkel, 2006). The literature clearly indicates that minimally qualified nursing students are the ones most likely to fail the NCLEX-RN (Beeson & Kissling, 2001; CPEC, 2003; Seldomridge & DiBartolo, 2004; Stuenkel, 2006; Uyehara, Magnussen, Itano, & Zhang, 2007). Beeson and Kissling (2001) reported that students who passed the NCLEX-RN had significantly higher sophomore nursing GPAs than students who failed the examination and that students who received even one C grade during the sophomore year were more likely to fail the examination than students who received As and Bs. However, the most significant predictor of NCLEX-RN success reported by Beeson and Kissling was the number of Cs, Ds, or Fs students received in their nursing courses through the junior year. Students without any grades of C or below had an NCLEX-RN passing rate of 97%. Students with one grade of C or below in a nursing course had a passing rate of 84%. However, BSN students with three or more Cs, Ds, or Fs had passing rates of just 51% (Beeson & Kissling, 2001). It has been suggested that nursing programs and students, alike, need data beyond nursing program GPA to better understand who is at risk of failing the NCLEX-RN (Stuenkel, 2006). As a result, many BSN programs have begun to require senior-level students to take a pre-NCLEX-RN assessment test at or near the end of the nursing major (Brown & Marshall, 2008; Stuenkel, 2006). One such assessment is the RN Comprehensive Predictor by ATI (2007a), which is designed to assess nursing students' comprehensive knowledge prior to graduation. Items on the RN Comprehensive Predictor reflect the nursing process and “mirror the NCLEX-RN test plan for content” (ATI, para. 2). Student performance on the RN Comprehensive Predictor is said to be “96% predictive of outcomes on the NCLEX-RN” (ATI, para. 1). However, no
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empirical literature was found that discussed whether aptitude, scholastic and/or nursing, was predictive of NCLEX-RN readiness. It is important for BSN programs to understand their applicants' scholastic and nursing aptitudes to more fully understand how such data may help identify BSN students at risk for progression and retention issues and how prenursing variables affect NCLEX-RN readiness. Such data can also be used to help identify BSN students who are likely to need additional assistance or remediation (Beeson & Kissling, 2001; Newton et al., 2007), as well as those who should, perhaps, be counseled out of the nursing major (Stuenkel, 2006). With little known regarding whether aptitude was predictive of long-term BSN student attrition or NCLEX-RN readiness, a gap in the literature exists. As a result, the following research questions were developed to guide this study: 1. Does prenursing scholastic aptitude predict
BSN student attrition prior to the final semester of the nursing major? 2. Does nursing aptitude predict BSN student attrition prior to the final semester of the nursing major? 3. Does prenursing scholastic aptitude predict NCLEX-RN readiness among BSN students? 4. Does nursing aptitude predict NCLEX-RN readiness among BSN students?
Methodology The study design was exploratory descriptive.
Sample The participants in this study consisted of one cohort of nursing students who were admitted to a large, Midwestern state-supported baccalaureate nursing program in the fall of 2004 (n = 107, n = 104 full-time, and n = 3 part-time). All first semester nursing students were expected to take the TEAS when it was administered during the first month of the nursing major. Of the original cohort of full-time BSN students, 94 took the RN Comprehensive Predictor examination (ATI, 2007a) during the fourth week of the final semester of the nursing curriculum or an attrition rate of 10%. For the 10 students who did not progress with their original cohort to the final semester of the nursing major, each had failed one nursing course, was placed on academic probation, and experienced a delayed graduation. The final sample for this study was composed of the 94 fulltime BSN students who had both TEAS and RN Comprehensive Predictor examination data available.
Measures There were two dependent variables: attrition late in the nursing program and NCLEX-RN readiness. Attrition was operationally defined as the number of students who did not progress to the final semester of the nursing major on schedule because of academic failure. Academic failure was defined as a student receiving one or more
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nursing course grades less than 2.5. NCLEX-RN readiness was defined as a student's percentage score on the RN Comprehensive Predictor examination (ATI, 2007a). The two independent variables were scholastic aptitude and nursing aptitude. Scholastic aptitude was operationally defined as a student's prenursing GPA. The prenursing GPA was calculated from final grades in seven required prenursing courses (biology, anatomy and physiology, chemistry, biochemistry, psychology, composition I, and composition II). Nursing aptitude was operationalized as the TEAS individual composite score calculated by ATI. The TEAS, consisting of four components, math, science, reading, and English, is designed to predict academic success in a program of study in nursing (ATI, 2007a).
Procedure The data for this study were part of an undergraduate curriculum evaluation initiative, and as such, institutional review board approval was not needed. However, the researchers paid careful attention to the protection of participant confidentiality. Relevant data were entered into a computer-based spreadsheet designed specifically for this study and which was only accessible by one of the study investigators. All data were kept confidential, no identifying information was included for any of the participants, and results were reported only in aggregate form. Data for this study were obtained from sources accessible to nursing program faculty. Prenursing course grades were retrieved from the study institution's prenursing database. TEAS individual composite scores were obtained from the ATI website, as were the RN Comprehensive Predictor examination scores. Attrition was calculated by subtracting the number of students who progressed to the final semester of the nursing major from the number who began as full-time students when the cohort was admitted. To assess which students did not progress due to academic failure versus other potential causes, data were obtained from the students' academic records. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 15.0.
Results Logistic regression was used to examine the multivariate effects of scholastic aptitude and nursing aptitude on attrition; neither was predictive. Regression analysis using stepwise entry was used to assess the multivariate effects of scholastic and nursing aptitude on NCLEX-RN readiness. The final model indicated that scholastic aptitude was predictive of NCLEX-RN readiness (P = .015), but nursing aptitude was not (P = .329). To further explore the concept of scholastic aptitude, a second variable composed of students who had at least one prenursing grade less than 2.5 was created to assess the impact low prenursing grades had on long-term attrition and NCLEX-RN readiness. Further, Newton et al. (2007) demonstrated in a previous study that prenursing GPA was predictive of first semester success in the nursing major. What was not known was whether
first semester success, operationalized as first semester nursing GPA, was predictive of long-term attrition and/or NCLEX-RN readiness. Prenursing grades less than 2.5 had a moderately strong negative relationship with prenursing scholastic aptitude (r = −.424) but were not related to long-term attrition or NCLEX-RN readiness. On the other hand, first semester nursing success had a weak positive relationship with long-term attrition (r = .314) and NCLEX-RN readiness (r = .275). Regression analysis using stepwise entry was used to examine the multivariate effects of scholastic aptitude, nursing aptitude, first semester nursing success, and attrition on NCLEXRN readiness. The final model indicated that first semester nursing GPA was most predictive of NCLEXRN readiness (P = .043); the other variables were all excluded from the final model.
Discussion The results of this study indicated that although neither prenursing scholastic aptitude nor nursing aptitude was predictive of long-term BSN student attrition, prenursing scholastic aptitude and first semester nursing success were both predictive of NCLEX-RN readiness among this sample's cohort of BSN students. The findings of this study can be partially explained by looking at the results of previous studies reported by Newton et al. (2007) and Newton, Smith, Moore, et al. (2007). Newton et al. (2007) reported that prenursing GPA and TEAS scores were predictive of first semester success in the nursing major and that first semester success was associated with having a higher prenursing GPA and higher TEAS scores. More importantly, attrition after the first semester of the nursing major (e.g., having one or more nursing grades less than 2.5) was related to having one or more prenursing grades less than 2.5 (Newton et al.). Newton, Smith, Moore, et al. (2007) wrote that scholastic aptitude was predictive of BSN early academic achievement but that only 15.4% of the variance was accounted for by scholastic aptitude. Newton, Smith, Moore, et al. (2007) felt that the small amount of variance accounted for in early academic achievement might be related to the heterogeneity of scholastic aptitude among students early in the nursing program. They hypothesized that as students progressed through the nursing curriculum, the heterogeneity in scholastic aptitude would decrease because weaker students would leave the program or be dismissed. The findings of this study support this idea in that weaker students with academic failures withdrew from the original student cohort resulting in greater homogeneity in scholastic aptitude among the remaining students.
Implications for Nursing Education With BSN student attrition rates high and NCLEX-RN performance declining across the United States (Brown & Marshall, 2008; Stuenkel, 2006), various studies have attempted to identify academic and nonacademic variables that affect the two phenomena, but the development
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of a comprehensive model of prediction has been complicated by the “…enigmatic interaction of demographic, academic, and psychosocial variables” (DiBartolo & Seldomridge, 2005, p. 166) investigated. Seldomridge and DiBartolo (2004) recommend that ongoing research to identify additional preadmission academic factors (e.g., number of course repeats), as well as nonacademic factors (e.g., hours per week of employment) affecting attrition is warranted. Instead, we believe that core variables, not those that may have only a spurious relationship to attrition and NCLEX-RN readiness, need to be isolated and refined. The persistent investigation of serendipitous non-core variables related to BSN student attrition and NCLEX-RN readiness is not efficient, nor is it economical as this country's nursing shortage continues to go unabated (Brown & Marshall, 2008). Nurse educators need a parsimonious explanatory model of BSN student attrition that can be used to guide admission and progression policies to ensure that student retention is a priority and to help ensure that students ready for the NCLEX-RN are the ones graduating from BSN programs. Aptitude continues to be predictive of BSN student success, even as BSN student demographics and prenursing educational backgrounds change (Brown & Marshall, 2008; Newton, 2008; Stuenkel, 2006). Currently, most of the research related to attrition and NCLEX-RN readiness operationalizes contextual environmental factors (CEFs) on the same level as the core predictor variables, most often aptitude. The shift we propose is to recognize that the CEFs are not predictors of the two phenomena but rather they have a moderating effect on them by exerting their influence in either positive (e.g., few students with English as a second language) or negative (e.g., large numbers of students who work full time) ways. Thus, it behooves nurse educators to stop searching for the “variable of the day” and instead focus their attentions on the core predictor variables that are known and that continue to be predictive of BSN student attrition and NCLEX-RN readiness, namely, aptitude. Tentative theory developed from the findings of this and other studies in the literature (e.g., Crow, Handley, Morrison, & Mitchell, 2004; Newton et al., 2007; Newton, Smith, Moore, et al., 2007; DiBartolo & Seldomridge, 2005) should be used to develop an explanatory model of the phenomena for use by BSN programs, nationwide, to curtail BSN student attrition and promote NCLEX-RN success. The model that is beginning to emerge indicates that prenursing grades less than 2.5 are associated with having a weak scholastic aptitude. Prenursing scholastic aptitude is predictive of first semester nursing success and NCLEX-RN readiness. Finally, first semester nursing success is positively related to both progression on schedule to the final semester of the nursing major and NCLEX-RN readiness.
Limitations The major limitation of this study was that the sample was one of convenience. Specifically, the participants represented only one cohort of BSN students from one
baccalaureate nursing program. As a result, the findings of this study may not be generalizable to all BSN students.
Conclusion In conclusion, the findings of this research have implications for both theory development and research related to BSN student attrition and NCLEX-RN readiness. The time is now for nurse educators to use the empirical findings cited in the literature to develop a model that both explains and predicts BSN student attrition and NCLEX readiness. For the research related to these phenomena to be of benefit to nurse educators, the core variable(s), namely aptitude, need to be recognized and the moderating effects of CEFs elucidated. However, challenges for the future remain, including elaborating on valid and reliable measures of aptitude, especially because the concept has relied, historically, on quantitative (e.g., GPA, TEAS scores) versus qualitative measures.
References Assessment Technologies Institute. (2007). RN comprehensive predictor. Retrieved May 20, 2007 from http://www.atitesting. com/productinfo/RNComprehensivePredictor.aspx. Assessment Technologies Institute. (2007). Test of Essential Academic Skills. Retrieved May 20, 2007 from http://www. atitesting.com/productinfo/TEAS.aspx. Beeson, S. A. & Kissling, G. (2001). Predicting success for baccalaureate graduates on the NCLEX-RN. Journal of Professional Nursing, 17, 121–127. Brown, J. & Marshall, B. L. (2008). A historically Black university's baccalaureate enrollment and success tactics for registered nurses. Journal of Professional Nursing, 24, 21–29. California Postsecondary Education Commission. (2003). Admission policies and attrition rates in California community college nursing programs. Commission report 03-2. Retrieved May 20, 2007 from http://www.cpec.ca.gov/completereports/ 2003reports/03-02.pdf. Crow, C. S., Handley, M., Morrison, R. S., & Shelton, M. (2004). Requirements and interventions used by BSN programs to promote and predict NCLEX-RN success: A national study. Journal of Professional Nursing, 20, 174–186. DiBartolo, M. C. & Seldomridge, L. A. (2005). A review of intervention studies to promote NCLEX-RN success of baccalaureate students. Nurse Educator, 30, 166–171. Gardner, J. (2005). A successful minority retention project. Journal of Nursing Education, 44, 564–568. Newton, S. E. (2008). The impact of community college transfer on entry-level baccalaureate nursing student retention. Nurse Educator, 33, 45–48. Newton, S. E., Smith, L. H., & Moore, G. (2007). Baccalaureate nursing program admission policies: Promoting success or facilitating failure? Journal of Nursing Education, 46, 439–444. Newton, S. E., Smith, L. H., Moore, G., & Magnan, M. (2007). Predicting early academic achievement in a baccalaureate nursing program. Journal of Professional Nursing, 23, 144–149. Peter, C. (2005). Learning—Whose responsibility is it? Nurse Educator, 30, 159–165. Potolsky, A., Cohen, J., & Saylor, C. (2003). Academic performance of nursing students: Do prerequisite grades and tutoring make a difference? Nursing Education Perspectives, 24, 246–250.
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Seldomridge, L. A. & DiBartolo, M. C. (2004). Can success and failure be predicted for baccalaureate graduates on the computerized NCLEX-RN? Journal of Professional Nursing, 20, 361–368. Stuenkel, D. L. (2006). Do theory grades + standardized examinations = success? Nurse Educator, 31, 207–212. Symes, L., Tart, K. & Travis, L. (2005). An evaluation of the Nursing Success Program: Reading comprehension,
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graduation rates, and diversity. Nurse Educator, 30, 217–220. Townsend, B. K. (1995). Community college transfer students: A case study of survival. The Review of Higher Education, 18, 175–193. Uyehara, J., Magnussen, L., Itano, J., & Zhang, S. (2007). Facilitating program and NCLEX-RN success in a generic BSN program. Nursing Forum, 42, 31–38.
AND
GARY MOORE, PHD, RN*
Attrition is a serious issue among Bachelor of Science in Nursing (BSN) students with attrition rates around 50% nationwide. To help minimize BSN student attrition, many nursing programs use commercially available standardized nursing aptitude tests as adjuncts to scholastic aptitude data, usually operationalized as pre-nursing grade point average, to select students for admission. Little is known regarding the usefulness of scholastic and nursing aptitude data for predicting long-term retention in a BSN program and readiness for the National Council Licensure Examination-Registered Nurse (NCLEX-RN). Therefore, the purpose of this study was to describe the relationships among scholastic aptitude, nursing aptitude, BSN student attrition prior to the final semester of the curriculum, and BSN student readiness for the NCLEX-RN. This study's findings, along with other findings in the literature, suggest the need for a parsimonious explanatory model of BSN student attrition that can be used to guide admission and progression policies, and ensure that students ready for the NCLEX-RN are the ones graduating from BSN programs. (Index words: Aptitude; Student attrition; NCLEX-RN, Undergraduate nursing) J Prof Nurs 25:273–278, 2009. © 2009 Elsevier Inc. All rights reserved.
A
PTITUDE IS THE complexity of knowledge needed by today's nursing students and can be broken down into nursing and scholastic aptitude. Nursing aptitude is more specific knowledge than scholastic aptitude and can be operationalized as college-level competencies in English, math, science, and reading comprehension (Newton, Smith, & Moore, 2007). Because baccalaureate nursing (BSN) curricula are academically rigorous, the literature indicates that BSN students who are admitted with strong scholastic and nursing aptitudes are less likely than students admitted
*Associate Professor, Oakland University, Rochester, MI. Address correspondence to Dr. Newton: Associate Professor, Oakland University, 448 O'Dowd Hall, Rochester, MI 48309. E-mail: [email protected] 8755-7223/$ - see front matter
with weak aptitudes to have progression/retention issues (Brown & Marshall, 2008; Gardner, 2005; Newton et al., 2007; Peter, 2005; Symes, Tart, & Travis, 2005). BSN student attrition can be curtailed when nursing program admission practices select applicants with high scholastic and nursing aptitudes (DiBartolo & Seldomridge, 2005; Newton et al., 2007; Stuenkel, 2006), but successful progression through the curriculum does not necessarily guarantee student readiness for the National Council Licensure Examination-Registered Nurse (NCLEX-RN). Nationwide, many BSN programs use commercially available standardized nursing aptitude tests along with scholastic aptitude to select candidates for admission to the nursing major (Assessment Technologies Institute [ATI], 2007b; Newton et al., 2007; Newton, Smith, Moore, & Magnan, 2007; Stuenkel, 2006). However, little empirical data exist that describes whether long-term retention in a BSN program
Journal of Professional Nursing, Vol 25, No 5 (September–October), 2009: pp 273–278 © 2009 Elsevier Inc. All rights reserved.
273 doi:10.1016/j.profnurs.2009.01.016
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NEWTON AND MOORE
and readiness for the NCLEX-RN can be predicted using student aptitude data. The purposes of this study were (a) to describe the relationships among prenursing scholastic aptitude, nursing aptitude, and student attrition prior to the final semester of a BSN program and (b) to assess the relationships among prenursing scholastic aptitude, nursing aptitude, and scores attained on a pre-NCLEX-RN assessment used to gauge senior students' readiness for the NCLEX-RN.
Literature Review Attrition among nursing students is a serious problem. Attrition is usually defined as “departure from a nursing program without successful completion of the program; but also can be defined to include students who are delayed in their progress toward program completion” (California Postsecondary Education Commission [CPEC], 2003, p. 12). Although the National League for Nursing Accrediting Commission suggests 80% as an acceptable retention rate for BSN programs, graduation rates for BSN programs are less than 50% nationwide (Brown & Marshall, 2008; Peter, 2005). High rates of attrition from nursing programs have been attributed primarily to the admission of minimally qualified students, specifically those not sufficiently prepared academically to begin the nursing major (Brown & Marshall, 2008; CPEC, 2003; Gardner, 2005; Newton, 2008; Newton et al., 2007; Symes et al., 2005). The literature indicates that BSN programs with more stringent admission policies may effectively “weed out” students who would otherwise be unsuccessful during the nursing major or fail the NCLEXRN (DiBartolo & Seldomridge, 2005; Newton et al., 2007; Stuenkel, 2006). However, even with more stringent admission policies, students who only minimally meet admission criteria often have academic difficulties after starting the nursing program (CPEC, 2003; Newton et al., 2007; Stuenkel, 2006). Preparedness for the nursing major can be evidenced in a number of ways (Stuenkel, 2006), but Seldomridge and DiBartolo (2004) believe that assessing the number of individual pre-nursing course grades a student has that are less than 2.5, not just overall pre-nursing grade point average (GPA), is potentially predictive of NCLEX-RN success. Similarly, Newton et al. (2007) reported that a rolling admission policy that facilitated large numbers of students being admitted to the nursing major contributed to issues with attrition following the first semester of the nursing curriculum. Students in the study by Newton et al. (2007) were admitted to either a Fall or a Winter cohort at one BSN program. Among the Fall cohort, 32 students (31%) had at least one prenursing course grade less than 2.5, whereas the Winter cohort had 48 students (63 %) with at least one prenursing grade less than 2.5. Newton et al. (2007) found that after the first semester of the nursing major, the attrition rates differed between the two cohorts. The Fall cohort had an attrition rate of 2% (2/103); the Winter cohort's attrition rate was 10% (7/ 70). The results of the study by Newton et al. (2007)
indicated that students with prenursing grades less than 2.5 contribute to program attrition. According to Gardner (2005), students who have a greater allegiance to an institution are likely to have better retention and graduation rates and that student retention is related to students being integrated into the social and intellectual life of the university. Gardner believes that students who are less integrated experience a lack of interaction and feel isolated from the daily life of the institution. Further, student failure to establish significant personal ties to the institution strongly affects their willingness to persist at the institution and is thought to be a large factor affecting the retention of students in higher education (Brown & Marshall, 2008; Gardner, 2005). One variable that may contribute to lack of integration among BSN students is transferring to the nursing program after starting one's post-secondary education at a community college (Newton, 2008). In a review of the literature, Newton addressed the potential impact community college transfer may have on BSN student retention. The literature identified that the milieu of community colleges tends to be student centered and designed to raise self-esteem (Townsend, 1995). Newton suggests that BSN students who initiate their postsecondary educations at community colleges are potentially at higher risk for attrition than students who initiate their post-secondary educations at a 4-year college or university. In order for BSN programs to identify the best predictors of academic achievement and to facilitate retention efforts, standardized nursing aptitude tests have been suggested as possible adjuncts to other available admission data (Crow, Handley, Morrison, & Shelton, 2004; Newton, Smith, Moore, et al., 2007; Stuenkel, 2006). One such test, the Test of Essential Academic Skills (TEAS) from ATI, can be used as part of the selection process for admitting students into post-secondary education programs (ATI, 2007b). The TEAS consists of four content areas: math, reading, English, and science (ATI). According to ATI, the TEAS was designed to predict those candidates with the highest likelihood of academic success prior to admission to a program of study in nursing. A study by Newton, Smith, Moore, et al. (2007) reported that the TEAS was able to predict first semester nursing program success. In addition, for sophomore students at risk of failure (operationalized as the number of pre-nursing course grades less than 2.5), the TEAS was a more reliable predictor of first semester success than was pre-nursing GPA. Newton, Smith, Moore, et al. (2007) concluded that early academic achievement depends on BSN programs admitting academically strong candidates into the program and that the TEAS provides additional data about students' core knowledge beyond that provided by pre-nursing GPA alone. Overcoming academic deficiencies is difficult for most students (Potolsky, Cohen, & Saylor, 2003), and students who are academically ill-prepared for the rigors of a BSN curriculum do not benefit emotionally or financially by
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being admitted and then failing during the program. Symes et al. (2005) discussed the need for successful retention programs for nursing students who, despite high GPAs in prerequisite courses, may encounter academic difficulties in BSN programs. Symes et al. described one such retention program, the Nursing Success Program (NSP), which was implemented for high-risk nursing students at Texas Woman's UniversityHouston Center. Students were identified as high risk based on the reading scores they obtained on the Nurse Entrance Test (NET), a scholastic aptitude test manufactured by Educational Resources, Inc. Symes et al. decided to use the reading comprehension scores as the advisement tool based on preliminary findings, suggesting that low NET reading comprehension scores were associated with higher rates of attrition. Prior to implementing the NSP, graduation rates for students with low reading comprehension scores were less than 50%. After the NSP was initiated, the high-risk nursing students had graduation rates similar to those students not assessed as highrisk (81%, respectively; Symes et al., 2005). Even when BSN students are successful in graduating from a nursing program, they are still, potentially, at high risk of failing the NCLEX-RN (Seldomridge & DiBartolo, 2004; Stuenkel, 2006). The literature clearly indicates that minimally qualified nursing students are the ones most likely to fail the NCLEX-RN (Beeson & Kissling, 2001; CPEC, 2003; Seldomridge & DiBartolo, 2004; Stuenkel, 2006; Uyehara, Magnussen, Itano, & Zhang, 2007). Beeson and Kissling (2001) reported that students who passed the NCLEX-RN had significantly higher sophomore nursing GPAs than students who failed the examination and that students who received even one C grade during the sophomore year were more likely to fail the examination than students who received As and Bs. However, the most significant predictor of NCLEX-RN success reported by Beeson and Kissling was the number of Cs, Ds, or Fs students received in their nursing courses through the junior year. Students without any grades of C or below had an NCLEX-RN passing rate of 97%. Students with one grade of C or below in a nursing course had a passing rate of 84%. However, BSN students with three or more Cs, Ds, or Fs had passing rates of just 51% (Beeson & Kissling, 2001). It has been suggested that nursing programs and students, alike, need data beyond nursing program GPA to better understand who is at risk of failing the NCLEX-RN (Stuenkel, 2006). As a result, many BSN programs have begun to require senior-level students to take a pre-NCLEX-RN assessment test at or near the end of the nursing major (Brown & Marshall, 2008; Stuenkel, 2006). One such assessment is the RN Comprehensive Predictor by ATI (2007a), which is designed to assess nursing students' comprehensive knowledge prior to graduation. Items on the RN Comprehensive Predictor reflect the nursing process and “mirror the NCLEX-RN test plan for content” (ATI, para. 2). Student performance on the RN Comprehensive Predictor is said to be “96% predictive of outcomes on the NCLEX-RN” (ATI, para. 1). However, no
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empirical literature was found that discussed whether aptitude, scholastic and/or nursing, was predictive of NCLEX-RN readiness. It is important for BSN programs to understand their applicants' scholastic and nursing aptitudes to more fully understand how such data may help identify BSN students at risk for progression and retention issues and how prenursing variables affect NCLEX-RN readiness. Such data can also be used to help identify BSN students who are likely to need additional assistance or remediation (Beeson & Kissling, 2001; Newton et al., 2007), as well as those who should, perhaps, be counseled out of the nursing major (Stuenkel, 2006). With little known regarding whether aptitude was predictive of long-term BSN student attrition or NCLEX-RN readiness, a gap in the literature exists. As a result, the following research questions were developed to guide this study: 1. Does prenursing scholastic aptitude predict
BSN student attrition prior to the final semester of the nursing major? 2. Does nursing aptitude predict BSN student attrition prior to the final semester of the nursing major? 3. Does prenursing scholastic aptitude predict NCLEX-RN readiness among BSN students? 4. Does nursing aptitude predict NCLEX-RN readiness among BSN students?
Methodology The study design was exploratory descriptive.
Sample The participants in this study consisted of one cohort of nursing students who were admitted to a large, Midwestern state-supported baccalaureate nursing program in the fall of 2004 (n = 107, n = 104 full-time, and n = 3 part-time). All first semester nursing students were expected to take the TEAS when it was administered during the first month of the nursing major. Of the original cohort of full-time BSN students, 94 took the RN Comprehensive Predictor examination (ATI, 2007a) during the fourth week of the final semester of the nursing curriculum or an attrition rate of 10%. For the 10 students who did not progress with their original cohort to the final semester of the nursing major, each had failed one nursing course, was placed on academic probation, and experienced a delayed graduation. The final sample for this study was composed of the 94 fulltime BSN students who had both TEAS and RN Comprehensive Predictor examination data available.
Measures There were two dependent variables: attrition late in the nursing program and NCLEX-RN readiness. Attrition was operationally defined as the number of students who did not progress to the final semester of the nursing major on schedule because of academic failure. Academic failure was defined as a student receiving one or more
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nursing course grades less than 2.5. NCLEX-RN readiness was defined as a student's percentage score on the RN Comprehensive Predictor examination (ATI, 2007a). The two independent variables were scholastic aptitude and nursing aptitude. Scholastic aptitude was operationally defined as a student's prenursing GPA. The prenursing GPA was calculated from final grades in seven required prenursing courses (biology, anatomy and physiology, chemistry, biochemistry, psychology, composition I, and composition II). Nursing aptitude was operationalized as the TEAS individual composite score calculated by ATI. The TEAS, consisting of four components, math, science, reading, and English, is designed to predict academic success in a program of study in nursing (ATI, 2007a).
Procedure The data for this study were part of an undergraduate curriculum evaluation initiative, and as such, institutional review board approval was not needed. However, the researchers paid careful attention to the protection of participant confidentiality. Relevant data were entered into a computer-based spreadsheet designed specifically for this study and which was only accessible by one of the study investigators. All data were kept confidential, no identifying information was included for any of the participants, and results were reported only in aggregate form. Data for this study were obtained from sources accessible to nursing program faculty. Prenursing course grades were retrieved from the study institution's prenursing database. TEAS individual composite scores were obtained from the ATI website, as were the RN Comprehensive Predictor examination scores. Attrition was calculated by subtracting the number of students who progressed to the final semester of the nursing major from the number who began as full-time students when the cohort was admitted. To assess which students did not progress due to academic failure versus other potential causes, data were obtained from the students' academic records. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 15.0.
Results Logistic regression was used to examine the multivariate effects of scholastic aptitude and nursing aptitude on attrition; neither was predictive. Regression analysis using stepwise entry was used to assess the multivariate effects of scholastic and nursing aptitude on NCLEX-RN readiness. The final model indicated that scholastic aptitude was predictive of NCLEX-RN readiness (P = .015), but nursing aptitude was not (P = .329). To further explore the concept of scholastic aptitude, a second variable composed of students who had at least one prenursing grade less than 2.5 was created to assess the impact low prenursing grades had on long-term attrition and NCLEX-RN readiness. Further, Newton et al. (2007) demonstrated in a previous study that prenursing GPA was predictive of first semester success in the nursing major. What was not known was whether
first semester success, operationalized as first semester nursing GPA, was predictive of long-term attrition and/or NCLEX-RN readiness. Prenursing grades less than 2.5 had a moderately strong negative relationship with prenursing scholastic aptitude (r = −.424) but were not related to long-term attrition or NCLEX-RN readiness. On the other hand, first semester nursing success had a weak positive relationship with long-term attrition (r = .314) and NCLEX-RN readiness (r = .275). Regression analysis using stepwise entry was used to examine the multivariate effects of scholastic aptitude, nursing aptitude, first semester nursing success, and attrition on NCLEXRN readiness. The final model indicated that first semester nursing GPA was most predictive of NCLEXRN readiness (P = .043); the other variables were all excluded from the final model.
Discussion The results of this study indicated that although neither prenursing scholastic aptitude nor nursing aptitude was predictive of long-term BSN student attrition, prenursing scholastic aptitude and first semester nursing success were both predictive of NCLEX-RN readiness among this sample's cohort of BSN students. The findings of this study can be partially explained by looking at the results of previous studies reported by Newton et al. (2007) and Newton, Smith, Moore, et al. (2007). Newton et al. (2007) reported that prenursing GPA and TEAS scores were predictive of first semester success in the nursing major and that first semester success was associated with having a higher prenursing GPA and higher TEAS scores. More importantly, attrition after the first semester of the nursing major (e.g., having one or more nursing grades less than 2.5) was related to having one or more prenursing grades less than 2.5 (Newton et al.). Newton, Smith, Moore, et al. (2007) wrote that scholastic aptitude was predictive of BSN early academic achievement but that only 15.4% of the variance was accounted for by scholastic aptitude. Newton, Smith, Moore, et al. (2007) felt that the small amount of variance accounted for in early academic achievement might be related to the heterogeneity of scholastic aptitude among students early in the nursing program. They hypothesized that as students progressed through the nursing curriculum, the heterogeneity in scholastic aptitude would decrease because weaker students would leave the program or be dismissed. The findings of this study support this idea in that weaker students with academic failures withdrew from the original student cohort resulting in greater homogeneity in scholastic aptitude among the remaining students.
Implications for Nursing Education With BSN student attrition rates high and NCLEX-RN performance declining across the United States (Brown & Marshall, 2008; Stuenkel, 2006), various studies have attempted to identify academic and nonacademic variables that affect the two phenomena, but the development
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of a comprehensive model of prediction has been complicated by the “…enigmatic interaction of demographic, academic, and psychosocial variables” (DiBartolo & Seldomridge, 2005, p. 166) investigated. Seldomridge and DiBartolo (2004) recommend that ongoing research to identify additional preadmission academic factors (e.g., number of course repeats), as well as nonacademic factors (e.g., hours per week of employment) affecting attrition is warranted. Instead, we believe that core variables, not those that may have only a spurious relationship to attrition and NCLEX-RN readiness, need to be isolated and refined. The persistent investigation of serendipitous non-core variables related to BSN student attrition and NCLEX-RN readiness is not efficient, nor is it economical as this country's nursing shortage continues to go unabated (Brown & Marshall, 2008). Nurse educators need a parsimonious explanatory model of BSN student attrition that can be used to guide admission and progression policies to ensure that student retention is a priority and to help ensure that students ready for the NCLEX-RN are the ones graduating from BSN programs. Aptitude continues to be predictive of BSN student success, even as BSN student demographics and prenursing educational backgrounds change (Brown & Marshall, 2008; Newton, 2008; Stuenkel, 2006). Currently, most of the research related to attrition and NCLEX-RN readiness operationalizes contextual environmental factors (CEFs) on the same level as the core predictor variables, most often aptitude. The shift we propose is to recognize that the CEFs are not predictors of the two phenomena but rather they have a moderating effect on them by exerting their influence in either positive (e.g., few students with English as a second language) or negative (e.g., large numbers of students who work full time) ways. Thus, it behooves nurse educators to stop searching for the “variable of the day” and instead focus their attentions on the core predictor variables that are known and that continue to be predictive of BSN student attrition and NCLEX-RN readiness, namely, aptitude. Tentative theory developed from the findings of this and other studies in the literature (e.g., Crow, Handley, Morrison, & Mitchell, 2004; Newton et al., 2007; Newton, Smith, Moore, et al., 2007; DiBartolo & Seldomridge, 2005) should be used to develop an explanatory model of the phenomena for use by BSN programs, nationwide, to curtail BSN student attrition and promote NCLEX-RN success. The model that is beginning to emerge indicates that prenursing grades less than 2.5 are associated with having a weak scholastic aptitude. Prenursing scholastic aptitude is predictive of first semester nursing success and NCLEX-RN readiness. Finally, first semester nursing success is positively related to both progression on schedule to the final semester of the nursing major and NCLEX-RN readiness.
Limitations The major limitation of this study was that the sample was one of convenience. Specifically, the participants represented only one cohort of BSN students from one
baccalaureate nursing program. As a result, the findings of this study may not be generalizable to all BSN students.
Conclusion In conclusion, the findings of this research have implications for both theory development and research related to BSN student attrition and NCLEX-RN readiness. The time is now for nurse educators to use the empirical findings cited in the literature to develop a model that both explains and predicts BSN student attrition and NCLEX readiness. For the research related to these phenomena to be of benefit to nurse educators, the core variable(s), namely aptitude, need to be recognized and the moderating effects of CEFs elucidated. However, challenges for the future remain, including elaborating on valid and reliable measures of aptitude, especially because the concept has relied, historically, on quantitative (e.g., GPA, TEAS scores) versus qualitative measures.
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