O
NLINE
C
ASE
S
TUDIES
: HESI E
XIT
E
XAM
S
CORES AND
NCLEX-RN O
UTCOMES
ANNE YOUNG, E
DD, RN⁎, GLORIA ROSE, P
HD, RN, FNP-BC
†,
AND
PAMELA WILLSON, P
HD, RN, FNP-BC, CNE
‡
Using data obtained for the 7th HESI Exit Exam (E2) validity study, the value of Elsevier's online case studies in assisting students to prepare for the E2 and the National Council Licensure Examination for Registered Nurses (NCLEX-RN) was investigated. Of the 137 randomly selected schools of nursing, 72 (52.55%) participated in the study. The student sample consisted of 4,383 students from associate degree, baccalaureate, and diploma schools of nursing. Findings indicated that the mean E2 score and the NCLEX-RN pass rate were significantly higher for students attending schools that used the case studies than they were for students attending schools that did not use the case studies. Descriptive data indicated that the case studies were most often used for remediation and examination preparation. (Index words: Case study; HESI Exit Exam; NCLEX-RN outcomes) J Prof Nurs 29:S17–S21, 2013. © 2013 Elsevier Inc. All rights reserved.
S
EVEN PREVIOUSLY PUBLISHED studies indicate that Elsevier's HESI Exit Exam (E2) is a highly accurate predictor of success on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) (Adamson & Britt, 2009; Lauchner, Newman, & Britt, 1999; Lewis, 2005; Newman, Britt, & Lauchner, 2000; Nibert & Young, 2001; Nibert, Young, & Adamson, 2002; Young & Willson, 2012). Consequently, many schools of nursing use the E2 as a predictor of students' preparedness for the licensure examination and as a guide for students' remediation needs. Numerous subject matter scores reported by the E2provide students with the information they need to focus remediationefforts that address their particular learning needs. However, methods used to prepare students for the licensure examination and to remediate academic weaknesses identified by the E2 so that candidates can achieve first-time success on the NCLEX-RN have not been adequately researched. A plethora of NCLEX-RN review books designed to assist students in reviewing content presented throughout the nursing curriculum are available for purchase. Yet, knowledge of content alone is not sufficient to achieve acceptable E2 scores, pass the NCLEX-RN, and perform compe-tently in the clinical area. Students and new graduates must also be able to apply nursing content and concepts to specific clinical situations and use critical thinking skills to solve clinical problems.
Review of the Literature
Case studies have long been used as a teaching method in business, law, and medicine because they provide an effective means of applying content and assisting students to develop problem-solving skills (Delpier, 2006). The use of case studies for teaching is generally considered superior to lectures in promoting learners' critical thinking skills, and students report a preference for interactive teaching strategies over didactic methods (Kim et al., 2006). Interestingly, despite students' pre-ference for interactive teaching strategies and faculties' belief that case studies are superior to didactic teaching
∗Professor, Texas Woman's University, College of Nursing, Houston, TX.
†Clinical Assistant Professor, Prairie View A&M University, College of Nursing, Houston, TX.
‡Associate Director of Education, Michael E. DeBakey VA Medical Center, Houston, TX.
Disclosure statement: Dr. Young and Dr. Rose have participated in research activities and received presentation honoraria from HESI Review & Testing within the past 3 years. Dr. Young serves as Chairperson of the Research Advisory Board for HESI Review & Testing. Dr. Willson was employed by HESI Review & Testing at the time this research was conducted.
Address correspondence to Dr. Young: Texas Woman's University, College of Nursing, 6700 Fannin, Houston, TX 77030. E-mail:eyoung@ mail.twu.edu
8755-7223/12/$ - see front matter
Journal of Professional Nursing, Vol 29, No. 2S (March/April), 2013: pp S17–S21 S17
methods, little or no difference has been found in terms of students' learning outcomes when comparing the use of case studies and didactic teaching strategies (Beers, 2005; Costa, van Rensburg, & Rushton, 2007; Lauver, West, Campbell, Herrold, & Wood, 2009). However, studies that compared teaching methods could have been affected by the methods used to evaluate learning outcomes, which were usually traditional tests that measured knowledge of content, rather than exams designed to measure critical thinking. The E2 and the NCLEX-RN, both of which are designed to measure critical thinking within the discipline of nursing, might be a better measure of the effectiveness of case studies in terms of students' learning outcomes. The use of case studies as a teaching strategy in nursing has been reported to promote critical thinking, develop students' clinical reasoning skills, and enhance students' prob-lem-solving abilities (Dowd & Davidhizar, 1999).
With the advent of instructional technology, innova-tive teaching strategies have been developed to assist students in achieving curricular and licensure success using self-paced learning opportunities. The online case studies provided by Elsevier are self-paced learning tools designed to assist students with the application of nursing knowledge and concepts in clinical situations, and as such, they are believed by many faculties to be an effective teaching strategy in helping students prepare for the E2 and the NCLEX-RN. Schools of nursing may purchase a license to use the Elsevier case studies, which are marketed as patient situations accompanied by critical thinking questions that help students learn to manage complex patient conditions and make sound clinical judgments. However, limited research has been conducted to study the effectiveness of these case studies as a teaching tool and/or a remediation resource.
Mihal (2006)is the only study completed to date that has investigated the effectiveness of Elsevier's online case studies. Using data obtained from Elsevier's database, Mihal divided schools into two groups: those that were licensed to use the case studies and those that were not licensed to use the case studies. Then, the mean E2scores for these two groups were compared. The mean E2score for the 1,544 students who attended the 34 schools of nursing that were licensed to use the case studies was 896.71, and the mean E2 score for the 21,241 students who attended the 344 schools of nursing that were not licensed to use the case studies was 859.88. A t test for two independent samples was used to compare the mean E2 score of students who attended schools that were licensed to use the case studies with the mean E2score of students who attended schools that were not licensed to use the case studies. Findings indicated that the mean E2 score for those who attended schools that were licensed to use the case studies was significantly higher (t = 9.979, P ≤ .000) than the mean E2 score for students who attended schools that were not licensed to use case studies, thereby suggesting that Elsevier's online case studies positively affected students' E2scores.
This study was designed to verify Mihal's findings regarding the E2 scores of students with and without access to case studies. However, since the Mihal study was completed, case studies' licenses have become a component of several testing packages, and current access to them does not necessarily mean that they are being implemented as a teaching strategy. This study determined users and nonusers of case studies based on deans' and directors' reported use of the case studies, rather than merely having a license to use the case studies. For the purpose of this study, two terms were defined: (a) case studies—Elsevier's online case studies that were licensed for use to schools of nursing; and (b) users of case studies—students who attended schools of nursing where deans and directors identified their school as a user of the case studies. Specifically, the purpose of this study was to (a) determine if E2scores of students who used the case studies differed from E2 scores of students who did not use the case studies, (b) determine if NCLEX-RN outcomes of candidates who used the case studies differed from NCLEX-RN outcomes of candidates who did not use the case studies, and (c) describe the methods used to implement the case studies.
Methodology
A nonexperimental, descriptive design was used to compare E2scores of students who used Elsevier's online case studies with E2scores of students who did not use the case studies. As part of the seventh E2validity study (S7), data were obtained from deans and directors at 72 randomly selected schools of nursing that administered the E2between September 1, 2006, and August 31, 2007 (Young & Willson, 2012). These participating deans and directors were asked to complete the S7 Participant School Survey, an electronic instrument that requested information regarding NCLEX-RN outcomes and use of the case studies. Additionally, data obtained from the three questions on the S7 Participant School Survey regarding case study implementation methods were used for descriptive purposes.
Instrumentation
Two instruments were used to obtain data for this study: the E2 and the S7 Participant School Survey. The E2 consists of 160 test items, 10 of which are pilot items that are not scored. It is a comprehensive exam that is administered to students near the completion of the nursing curriculum to measure their preparedness for the NCLEX-RN. The test items are written using a critical thinking model described byMorrison, Nibert, and Flick (2006) and require clinical nursing judgment to deter-mine the correct answer. Morrison, Adamson, Nibert, and Hsia (2004)described the reliability and validity of the E2. A reliability estimate or Kuder–Richardson Formula 20 (KR20) is calculated for every E2 prior to its administration and is based on item analysis data obtained from all previous uses of the test items contained in the exam. The mean estimated KR20 for the E2s administered during the study period was 0.926
(Elsevier's HESI database, August 2011). Criterion-related validity of the E2 has been established by the seven validity studies that have been conducted over the past 12 years, indicating that the E2 is between 96.36% and 99.16% accurate in predicting NCLEX-RN success (Adamson & Britt, 2009; Lauchner et al., 1999; Lewis, 2005; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002; Young & Willson, 2012).
The S7 Participant School Survey consisted of multi-ple-choice items with open comment fields. Data obtained from this instrument were used to determine students' outcomes on their first attempt at taking the NCLEX-RN and to glean descriptive data regarding strategies used to implement the case studies. All identifying information was removed prior to providing data to the researchers regarding NCLEX-RN pass rates and case study implementation methods.
Findings
Nursing schools were randomly selected to participate in S7, and of the 137 schools selected for participation, 72 (52.55%) responded to the Participant School Survey. Of the 72 responding nursing schools, 45 (62.50%) were associate degree (ADN) programs, 22 (30.56%) were baccalaureate (BSN) programs, and 5 (6.94%) were diploma programs. The total student sample consisted of 4,383: 2,557 (58.34%) ADN students; 1,617 (36.89%) BSN students; and 209 (4.77%) diploma students. Of the 72 participating schools, 24 (33.33%) schools reported that they used the Elsevier online case studies within their school of nursing, and 48 (66.67%) reported that they did not use the case studies. Of the total 4,383
participating students, 1,597 (36.44%) attended schools that used the case studies, and 2,786 (63.56%) attended schools that did not use the case studies (seeTable 1).
The mean E2score of the 1,597 students who used the case studies was 868.79, and the mean E2 score of the 2,786 students who did not use the case studies was 849.62. A t test analysis indicated that the students who used the case studies had significantly higher E2scores than the students who did not use the case studies, t(3,229) = 4.58, P≤ .000, (seeTable 2).
Of the 4,383 participating students, NCLEX-RN out-comes were unavailable for 462 students because they did not graduate, their NCLEX-RN outcomes were unavail-able to their deans or directors, or the deans or directors declined to provide the data. Therefore, the total student sample used for analysis regarding NCLEX-RN outcomes consisted of 3,921 students: 1,437 (36.65%) who used the case studies and 2,484 (63.35%) who did not use the case studies. Of the 1,437 students who used the case studies, 1,332 (92.69%) passed the NCLEX-RN on their first attempt, and 105 (7.31%) failed. Of the 2,484 students who did not use the case studies, 2,223 (89.49%) passed the NCLEX-RN on their first attempt, and 261 (10.51%) failed. Because NCLEX-RN outcomes are reported as pass/fail, which are nominal-level data, a chi-square was used to analyze the data. Findings indicated that significantly more students who used the case studies
Table 1. Description of Schools and Students by Program Type and HESI Case Study Use
Number of schools Number of students Program type ADN 45 2,557 BSN 22 1,617 Diploma 5 209 Total 72 4,383
HESI case study use
Used the case studies 24 1,597
Did not use the case studies 48 2,786
Total 72 4,383
Table 2. Comparison of Mean E2 Scores for Students Who Attended Schools That Used HESI Case Studies and Students Who Attended Schools That Did Not Use HESI Case Studies
HESI case study use n
Mean E2
score SD t P
Confidence interval 95%
Lower Upper
Students attending schools that used the case studies 1,597 868.79 135.07 4.58 ≤.000 10.95 27.37 Students attending schools that did not use the case studies 2,786 849.62 130.39
Total students 4,383
Note. Mean E2scores were significantly higher (P≤ .000) for students who attended schools that used HESI case studies than for students who attended schools that did not use HESI case studies.
Table 3. NCLEX-RN Outcomes of Students Who Attended Schools That Used HESI Case Studies and Students Who Attended Schools That Did Not Use HESI Case Studies
HESI case studies Number
Number (%) passed NCLEX-RN Number (%) failed NCLEX-RN Students attending schools that used the case studies
1,437 1,332 (92.69) 105 (7.31)
Students attending schools that did not use the case studies
2,484 2,223 (89.49) 261 (10.51)
Total 3,921⁎
Note. The NCLEX-RN pass rate was significantly higher for students who attended schools that used the HESI case studies than for students who attended schools that did not use the HESI case studies,χ2(1, N = 3,921) = 10.64, P≤ .001.
⁎NCLEX-RN outcomes were not available for 462 of the total sample of 4,383.
passed the NCLEX-RN on their first attempt than students who did not use the case studies, χ2(1, N = 3,921) = 10.64, P≤ .001, (seeTable 3).
Deans and directors of the 24 schools that reported using the case studies answered three questions on the S7 Participant School Survey regarding methods used to implement the case studies within their school of nursing. Based on data obtained from responses to these questions, the primary uses for the case studies were remediation and exam preparation. Of the 24 schools that used the case studies, 18 (75.00%) deans or directors described using the case studies for remedia-tion, and 15 (62.50%) described using the case studies for exam preparation. The case studies were used as part of the course grade by 8 (33.33%) of the schools, for clinical preparation by 6 (25.00%) of the schools, and for postclinical conferences by 5 (20.83%) of the schools (seeTable 4).
Summary, Discussion, and
Recommendations
This study was based on data obtained for S7, which investigated the predictive accuracy of the E2 by soliciting information from the deans or directors of the participating schools regarding students' NCLEX-RN outcomes. Data regarding schools' use of the Elsevier online case studies were reported by the deans or directors that responded to the S7 Participant School Survey. Mean E2 scores and NCLEX-RN pass rates of students who used the case studies and those who did not use the case studies were compared. Both E2scores and NCLEX-RN pass rates were significantly higher for students who used the case studies. It is likely that E2 scores and students' first-time NCLEX-RN success rate were higher for those who used the case studies because the case studies focus on application of content and require the use of critical thinking skills to answer the questions provided with each case study. The online case studies therefore provide students with valuable practice in using their nursing knowledge and critical thinking skills to solve clinical problems. However, the percentage of students at each school who completed the case studies and the percentage of case studies each student completed could not be determined. In reviewing the findings of this study, one must consider that the mean
scores could have been influenced by intervening vari-ables. For example, it is possible that the faculty at schools that used the case studies worked more closely with students in helping them remediate than did the faculty at schools that did not use the case studies, which might explain why they purchased the case study license in the first place—to help students remediate. Such faculty assistance might explain why students who used the case studies had higher E2 scores and a higher NCLEX-RN pass rate than students who did not use the case studies. Additionally, the quality of the student population at each school could have differed, thereby influencing the findings of this study. Future studies regarding the usefulness of case studies should investi-gate the E2 scores and NCLEX-RN outcomes of individual students, and researchers should also consider stratifying the sample by the number of the case studies each student completed, rather than simply looking at those who attended schools that reported using the case studies. As it was in this study, all identifying student information should be expunged prior to providing the data to the researchers so that the participants' confiden-tiality is protected.
This was a preliminary study that investigated methods used to implement case studies and, as such, provided descriptive data only. Future studies should obtain a larger sample size of schools that use the case studies and compare case study implementation methods in terms of E2 scores and NCLEX-RN outcomes, thereby scientifi-cally investigating the value of various methods used to implement case studies within schools of nursing.
Conclusions
Seven previously published studies indicate that the E2is highly accurate in predicting NCLEX-RN success, and the findings of this study provide nursing students and nursing faculty with direction in terms of preparing for the E2 and ultimately for the NCLEX-RN. Deans and directors reported that Elsevier's online case studies were most often used for remediation and exam preparation. It seems that the case studies were helpful with remedia-tion and exam prepararemedia-tion because both the mean E2 score and the NCLEX-RN pass rate were significantly higher for students who used the case studies than for students who did not use the case studies. It would therefore seem judicious for deans and directors to consider using the Elsevier online case studies to assist students in preparing for the E2and ultimately for the licensing exam.
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by Schools of Nursing That Used the HESI Case Studies
Method Number of schools Percent of schools Remediation 18 75.00 Exam preparation 15 62.50 Course grade 8 33.33 Clinical preparation 6 25.00 Postclinical conference 5 20.83 Total 24⁎
⁎More than one method may have been implemented by individual schools.
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