Enhancing Student Success On The Computer-Adaptive Test (Cat)
Version Of The National Council Licensure Examination
For Registered Nurses (Nclex-Rn)

Literature Review

Ronda M. Wood,  Graduate student, USC
o become a registered nurse, an individual must be accepted into 
a college with an accredited nursing program.  The requirements for 
applying to nursing programs vary from school to school.  The 
required prerequisite courses, such as anatomy, physiology, and 
microbiology, must be completed at the college with a grade point average 
of 2.0 or better.  After the prerequisites are completed, an application 
to the school of nursing can be made.  In the United States there are 
three types of nursing programs.  First, there are diploma programs, which 
involve two years of full time study.  These are mostly on the east coast 
and are remnants of the original hospital-based nursing schools.  Second, 
there are Associate Degrees in Nursing (ADN) programs that also require 
two years of full-time study.  In addition to the nursing curriculum, they 
require general education courses to obtain an ADN.  Third, there are 
Baccalaureate of Science in Nursing (BSN) programs that mandate four years 
of full time study.  The BSN programs are university based programs and 
require general education courses in addition to the nursing classes.  
After the nursing program is successfully completed, the candidate is 
eligible to take the National Council Licensure Examination for Registered 
Nurses (NCLEX-RN).  

Since it was first administered in July of 1982 (Arathuzik & Aber, 1998), 
the NCLEX-RN has undergone many changes.  It started as a two-day 
paper-and-pencil exam that tested each specialty area, such as medical, 
surgical, pediatrics, mental health, and women's health, separately.  Next 
the exam format was changed so that the specialties were blended together.  
However, it still was a two-day paper-and-pencil test.  The most recent 
change occurred in 1994.  At that time the exam was made into a 
Computer-Adaptive Test (CAT) version.  It is now given on computer and 
lasts an average of three to four hours.  The CAT version has presented 
new challenges for nursing school graduates and faculty.

School of nursing faculty must evaluate how their curricula prepare 
graduates for the CAT version of the examination.  Preparation for and 
test taking strategies utilized for computer exams differ from those for 
paper-and-pencil tests.  Most schools of nursing still give paper-and 
pencil tests in their courses; therefore, students are most familiar with 
taking paper-and-pencil examinations.  Faculty are beginning to utilize 
computer-assisted instruction (CAI), which will familiarize students with 
the use of computers.  The following question can be raised, are a few 
required CAI programs enough to produce maximal success on the exam?  
The differences between the two forms of tests may or may not be 
compensated for by the periodic use of CAI in nursing courses.  Prior 
to the computerized version of the NCLEX-RN, nursing faculty utilized 
techniques such as timing exams and phrasing questions in a similar manner 
to those on the NCLEX-RN to assist in the preparation of graduates for 
state board exams.  The literature does not reveal that programs have 
modified their test questions and examination techniques since 1994 to 
correlate with the CAT exam.  
This report is a literature review pertaining to the CAT version of the 
NCLEX-RN.  Research on the NCLEX-RN and other CAT examinations was read.  
The literature that was reviewed can be grouped according to three themes:  
predictors for success on the NCLEX-RN, preparation for the NCLEX-RN, and 
information on other CAT examinations.  The following will present the research 
found under each of the three areas. 

Much has been written on predicting student success on the NCLEX-RN.  The 
majority of studies focused on grades as predictors for success on the NCLEX-RN.  
Huepel, 1994, used nursing course and science course grades alone as the 
independent variables for her study.  As would be expected, school grades 
correlated positively with NCLEX-RN pass/fail rates.  Researchers began to
wonder if other factors influenced success on the exam.  Seven other studies 
analyzed grades with other independent variables such as sex, age at completion 
of the nursing program, high school grade point average (GPA), American College 
Testing (ACT) scores, Mosby ASSESSTEST scores, Scholastic Assessment Test (SAT) 
scores, did the student transfer to the program or change majors, were they on 
probation during the program, and did they take a ANR (American Nursing Review) 
course (Felts, 1986; Fowles, 1992; Huepel, 1994; Jenks, Selekman, Bross, & Paquet, 
1989; Mills, Sampel, Pohlman, Becker, 1992; Waterhouse, Bucher, & Beeman, 1994; 
Woodham & Taube, 1986).  In a 1990 publication, Lengacher & Keller utilized role 
strain as an independent variable in addition to the others mentioned above.  
Dell & Valine (1990) looked at GPA, SAT scores, ACT scores, and self-esteem as 
predictors for success.  Stress and role strain were found to have an influence 
on pass/fail rates in addition to grades (Lengacher, & Keller, 1990).  Although 
there is a lot of literature in this area and studies expanded to include 
predictors other than academic ones, only one study was found after the 1994 
implementation of the CAT version of the exam.  Arathuzik & Aber (1998) used the 
Internal Block Scale, the External Block Scale, and the Study Skills Self-Efficacy 
Instrument as predictors for success.  

Once predictors for success were established, researchers began to assess how to 
best prepare students for the examination.  Assisting students in preparation for 
the NCLEX-RN is a key role of nursing school faculty.  In order to better prepare 
students for the exam, faculty need to explore how students are preparing themselves.  
Colombraro (1989) found that the number one concern of  NCLEX-RN candidates was 
being unprepared/lacking knowledge.  Out of 143 candidates who were interviewed, 
51% stated that was what worried them the most.  She went on to look at how review 
books, groups led by a nurse educator as a facilitator, and individual review 
materials assisted in preparing the NCLEX-RN candidates.  This information is helpful; 
however, it must be modified to incorporate the CAT version of the exam.  Baradell, 
Durham, Angel, Kaufman, & Lowdermilk (1990) presented one college's approach to 
preparing NCLEX-RN candidates, and again this was done prior to the institution of 
the CAT version.  In a study published in 1994, Ashley & O'Neil examined study groups 
as a method for NCLEX-RN preparation.  In 1996 and 1997 reviews of various NCLEX-RN 
preparation programs were presented (Billings, Hodson-Carlton, Kirkpatrick, Aaltonen, 
Dillard, Richardson, Siktberg, & Vinten, 1996;  Riner, Mueller, Ihrke, Smolen, Wilson, 
Richardson, Stone, & Zwirn, 1997).  They arrived at advantages and disadvantages of 
the various preparation programs that were available.  In 1995, Patricia Beare published 
an article on assisting students in preparation for the CAT version of the state board 
examination.  She states that first faculty must teach students how to decrease their 
anxiety about the examination and then how to build their confidence.  Some suggestions 
to do that are reinforcing how to take multiple-choice tests, attending teacher-taught 
preparation seminars, flash cards, and review books.  Beare stresses the fact that school 
of nursing faculty must revise techniques for student exam preparation to correlate with 
the computer test.

Knowledge about other CAT examinations is helpful in understanding differences in 
preparation and test-taking strategies for the CAT version of the NCLEX-RN.  Two studies 
were found on CAT examinations other than the NCLEX-RN.  The first one explored measuring 
mathematical reasoning on a CAT (Bennett, Steffen, Singley, Morley, & Jaquemin, 1997).  
The researchers analyzed trials for a test that is being constructed by the Graduate 
Record Examinations Program, Mathematical Reasoning (MR).  This preliminary study found 
that the exam results were positive.  They concluded that more research is needed.  The 
second article examined testing the performance of middle school students on multiple-choice 
and written test questions via paper-and-pencil and computer formats  (Russell & Haney, 
1997).  The findings revealed that with multiple choice questions students' performance 
did not differ between the two modes of testing.  However, for the written tests students 
who were accustomed to writing on a computer did better than those who wrote by hand. 
In conclusion, this literature begins to give insight as to how to approach the topic of 
enhancing student success on the CAT version of the NCLEX-RN.  However, as can be seen 
by the above research findings, the literature with the CAT version is scant.  Researchers 
must begin to understand how to enhance success on the exam and not focus on predictors 
for success as those are well established.  One idea for gaining insight on how to increase 
students' success on the test is to gather data on how successful and unsuccessful candidates
prepared for the exam.  Students are given paper-and-pencil tests in nursing school and, 
therefore, are accustomed to studying for those types of tests.  As stated previously, 
computer examinations require different test-taking skills and preparation strategies.  
Information can be gathered on how candidates prepare for the test, and the data for 
successful and unsuccessful graduates can be compared and similarities and differences 
found.  Techniques utilized by successful candidates can be encouraged in all candidates 
to then increase general success rates.  


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