The National Council Licensure Examination (NCLEX) pass rates declined over the last three years among individuals pursuing their registered nurse licensure in the United States. Evidence of the decline in pass rates is related to the impact of the COVID-19 pandemic on new graduate nurses (NGNs). Some organizations hired NGNs without licensure during the pandemic due to NCLEX testing delays and unsuccessful pass rates (Chan et al., 2021). There is little to no published evidence that could guide hospitals in providing supportive remediation efforts for hired NGNs who are unsuccessful in their first attempt. This is what helped create Project EaRNed, its purpose being to support the NGN holistically with NCLEX remediation. Project EaRNed was implemented in the height of the pandemic in 2021 to close the gap between NCLEX failure after noting an increase of unsuccessful attempts in NGNs joining the organization. The project has an over 90% success rate going into its second year.  

Entering the Program

Once an NGN is unsuccessful with their NCLEX, leadership refers them to the Project EaRNed program for remediation. The intake form is a simple questionnaire to help better understand the background of the new graduate nurse and how they prepared for the exam. This tool is especially beneficial as the interview process of the program helps create the beginning of a mentoring relationship. The NGN then completes the digital intake form to include demographics, test date, number of questions on test, preparation for the exam, motivation to pass, type of support system at home, and questions about current mental health. Project EaRNed is then introduced to the NGN explaining the purpose and the plan for action.

Charles Corr (2021), who identified the importance of incorporating Kubler-Ross (1972) stages of grief (denial, anger, bargaining, depression, and acceptance) within clinical practice, was incorporated into the development of Project EaRNed to assist students with the grief and loss associated with academic failure. As such, before study sessions began, NGNs spend one week in detox. In this week, NGNs take dedicated time to go through the five stages of grief. NPD practitioners then make referrals to employee assistance programs for emotional assistance if necessary. This is an extremely difficult time for many, as they perceive their dreams as placed on hold until they are eligible to retest. Financial stability is another concern during this time, as without a passing NCLEX score, their pay is not that of a nurse, and their student loans would soon start to come out of deferment. The emphasis at this time is emotional support.

The Remediation Process

An important first step for NGNs participating in Project EaRNed is to wipe the slate clean—to forget what they heard from classmates, friends, and coworkers, and throw out the resources used to study on their first attempt. Next, NPDs advise NGNs to select one reliable, evidence-based platform containing the updated Next Generation NCLEX material. Many NGNs, in preparing for their first attempt, utilized multiple resources. Committing to one resource eliminated confusion in content and test-taking techniques. NPDs also advised working participants not to study on the days that they worked, or while they were on duty. Evaluation of the digital intake form showed that those who studied while working scored poorly on their practice test, decreasing their confidence.

Adult learning principles in Project EaRNed’s study plans include audio-visual videos and taking micro-breaks, with the goal of focusing on a blended type of learning. A main goal was to increase test-taking stamina, thus enhancing focus throughout the duration of a long exam. “The curse of 85” is a concept identified during the remediation process that often occurs once a test taker surpasses 85 questions during the NCLEX. At this point, NGNs may lose concentration and spiral, due to negative self-talk related to this question threshold. After evaluating the experiences of successful Project EaRNed participants, it was determined that answering 100 questions each study session helps to create and build on their test-taking stamina as well as help them distribute their allotted time accordingly.

Once a week, NPD practitioners instruct NGNs to alternate their practice exam questions between readiness assessment and computer-adaptive test (CAT). A readiness assessment provides questions at all levels of difficulty and on random topics, regardless of how the participant answered the previous question. This style of assessment provides feedback to the tester on the likelihood of passing the NCLEX, and it is the most favored tool to indicate preparedness by the participants of Project EaRNed. The CAT mimics the NCLEX because the computer adapts to how the NGN answers the previous question. For example, when an easy question is answered correctly, a harder question will be presented. When a question is answered incorrectly, the computer will adapt, dropping down the difficulty level of the next question until the NGN reaches the passing benchmark. Corrigan-Magaldi, Colalillo, and Molloy (2014) studied the effect of the utilization of an adaptive quizzing system with 11 at-risk nursing students, nine of whom ultimately passed the NCLEX following the testing strategy.

Additional Resources

As part of Project EaRNed, virtual NCLEX live sessions are held weekly for one hour. Each session covers a variety of pertinent topics and reviews practice questions of medium or hard difficulty. The live sessions also provide an opportunity for peer support for participants of all learning styles.

Another benefit of Project EaRNed is access to a coach who is an NPD practitioner or specialist within the organization. The role of the Project EaRNed coach includes assistance with obtaining authorization to test (ATT), scheduling the examination, discussing barriers that prevent one from studying, motivation throughout the process, and mentoring sessions. Participants are encouraged to maintain lines of communication open with the Project EaRNed coach for a minimum of three days a week to ensure progress. The constant communication keeps the participant accountable to their goals. 

An important piece to the success of an NGN in NCLEX remediation is the collaboration between their NPD practitioner and nursing leadership. This partnership allows flexibility with participants’ work and study schedules. Support and alignment from clinical and NPD leaders have proven crucial to the scheduling and attendance of the remediation process and live sessions.

Program Success

Since its creation in July of 2022, Project EaRNed has successfully remediated 38 new graduate nurses who remained employed at participating hospitals. Of this group, 34 of them were successful on their second attempt. The other four participants were those who were on their third and fourth attempt and wanted to remain part of the program until successfully passing. Nurses who were retained were employed in various units and specialties, including ED, ICU, pediatrics, acute care, progressive care, etc. All of these NGNs who participated in the program were eligible to join the nurse residency program and officially begin their careers within the hospital system, post-NCLEX.  

The American Association of Colleges of Nursing (AACN) developed the new competency-based education with an emphasis on clinical judgment, critical thinking/reasoning, and decision-making testing, calling it the Next Generation NCLEX. Therefore, the Next Generation NCLEX exam asks questions that help the nurse develop critical thinking skills while providing care. This became a source of worry for some due to the impact that the pandemic on nursing school education. Although we are still in the early stages of the announcement from the AACN, there are worries about the national pass rate dipping even further than it has. Many NGNs are still entering the profession with modified versions of nursing school created during the global pandemic. As NPD practitioners, we must prepare to remediate for the NCLEX as a part of our scope of practice. Creating a meaningful relationship with an NGN during a vulnerable time through a project like Project EaRNed will not only develop a stronger human connection but will also help increase nursing retention rates.  

Special thanks to Kate Williams, DNP, RN, NPD-BC, NEA-BC, and Marlene Porter, PhD, RN, NPD-BC, CEN, CCRN-K, for their unwavering support throughout the creation and development of this program. You two are the definition of transformational leadership!

References

Chan, G.K., Bitton, J.R., Allgeyer, R.L., Elliott, D., Hudson, L.R., Moulton Burwell, P., (May 31, 2021) "The Impact of COVID-19 on the Nursing Workforce: A National Overview" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 2, Manuscript 2. https://doi.org/10.3912/OJIN.Vol26No02Man02

Corr, C. A. (2021). Should We Incorporate the Work of Elisabeth Kulber-Ross in Our Current Teaching and Practice and, If So, How? OMEGA- Journal of Death and Dying, 83(4), 706-728. https://doi.org/10.1177/0030222819865397

Czekanski, K., & Mingo, S. (2018). Coaching to NCLEX-RN Success: A Postgraduation Intervention to Improve First-Time Pass Rates. Journal of Nursing Education, 57(9), 561-565. https://doi.org/10.3928/01484831-20180815-10

Pence, J., & Wood, F. (2018). Using Computer-Adaptive Quizzing as a Tool for National Council Licensure Examination Success. Nursing Education Perspectives, 39(3), 164-166. https://doi.org/10.1097/01.NEP.0000000000000289

Smith, A. L., & Meyer, L. A. (2021). A quality initiative for comprehensive integration of a standardized assessment product in nursing education. Teaching and Learning in Nursing, 16(1), 68-73. https://doi.org/10.1016/j.teln.2020.05.006

Zyhier, S. (2023). Preparation strategies for the 2023 NCLEX next generation exam: Methods to improve organized critical thinking and cognitive retention. Teaching and Learning in Nursing, 18(3), 402-409. https://doi.org/10.1016/j.teln.2023.04.022