Teamwork is an essential piece of healthcare for patient treatment, but it’s also the key ingredient to get registered nurses in place to care for them.
Teamwork, and buy-in from everyone involved in the process ― students, faculty and employers.
Virginia Western Community College’s Nursing Program leaned into teamwork when facing problematic pass rates on the NCLEX-RN exam, and assembled a model coaching program in 2022. This template is currently assisting this year’s graduates, who are taking the exam this summer.
Results were beyond expectations when 96.83% of the 2022 Nursing Program cohort passed on their first attempt, compared with a national benchmark of 77.91%. Of Virginia Western students testing in the April to September 2022 period, 100% passed on their first attempt.
“This is what happens when you’ve got a solid plan, that’s bought in on every level, so it’s administration, the faculty, and the students ― everybody’s pulling together and believes in this plan,” said Virginia Western Director of Nursing Lauren Hayward. The success is even more remarkable amid the immense disruptions of COVID.
When Commencement rolls around each spring, most students are ready to be free and start their new lives. But for students in the Associate of Applied Science in Nursing Program, Hayward explained, the time immediately after graduation is crucial ― and their work is far from complete. “It’s a really intensive six to eight weeks,” she said. Many have started onboarding with employers, but they must pass the National Council Licensure Examination to become registered nurses.
Nursing programs must see 80 percent or higher of graduates pass the NCLEX on first attempt. After three years below this mark, a program can lose approval. Virginia Western’s pass rates for 2020 and 2021 were each below that, at 79.66% and 78.00%, respectively.
Part of the Nursing program’s cohort includes licensed practical nurses who are advanced placed; they take a summer intensive semester, then complete Levels 3 and 4 of the program, each of which are a semester long. In May 2020, these LPNs graduated from the AAS program, but COVID prevented them from prepping for the NCLEX-RN exam. “It was a unique situation,” Hayward said. Many worked in nursing homes where people were dying of COVID. As a result, only 68.75% of the LPNs sitting for the NCLEX-RN passed on the first attempt. Even though 83.72% of traditional RN students passed, the overall average dragged below the 80 percent standard.
Previous to this, Virginia developed a common curriculum that took a decade to implement. About 80 percent of the state’s programs, including Virginia Western, launched the curriculum in 2018. The first students to progress through the program graduated in 2020 ― right as COVID hit.
As the pandemic wore on in 2021 and disrupted the availability of clinical rotations, the program stayed below the mark ― and so did the national average.
Multi-pronged approach
Even though they were horrified, Hayward said, she and her faculty remained focused. “We came up with a five-point plan that focused on student success. We changed resources, a really in-depth curriculum review ― not just evaluation, but changed items, re-emphasized content where they were testing low,” she said. They paid particular attention to content areas such as pharmacology that were consistently lower on NCLEX results. “It wasn’t that we added so much content as we emphasized it or did activities around the content that they were performing low in,” Hayward said.
Marilyn Herbert-Ashton is dean of nursing in addition to her role as vice president of institutional advancement for Virginia Western. “The nursing faculty took a deep dive in reviewing testing policy, transfer policy, curriculum revisions and the one area that they really tweaked, with concept-based curriculum, was really leaning into pharmacology,” she said. “Pharmacology requires an understanding of how the drug works, its effects and how the body utilizes the drug. Nurses must be able to evaluate a patient’s condition before administering medications and the patient’s response after receiving the medication.”
Hilda Taylor arrived at Virginia Western in January 2021 in the middle of the pandemic and this spring was finishing a 45-year career that has paired teaching concurrently with bedside nursing. She had previously implemented the concept-based curriculum in a pilot program at Reynolds Community College in Richmond, and then at what is now Laurel Ridge Community College. “I transferred to Virginia Western in the middle of the pandemic because they had a very solid teamwork. They insisted on maintaining nursing standards and education and testing in particular,” she said.
Taylor said that you can’t tease out the change in program format from COVID when analyzing students’ performance on the NCLEX.
“When we analyzed the NCLEX results of our students and then the NCLEX plan practice questions, we kept seeing reoccurring things that they were missing, and these were things we didn’t teach in detail. So we started adding things back to the curriculum,” Taylor said.
Fellow faculty member Kathy Smith gave an example of the team’s approach. “The reason why the concept curriculum was developed, is that nurses can’t know everything” ― the textbooks are just too large. “So people who developed the concept curriculum, 15-plus years ago, said we can teach concepts, and students should be able to figure out how your nursing actions, or nursing interventions, should be for that person who has a problem with oxygenation, or mobility, or nutrition, or gas exchange, or acid-base balance.”
The NCLEX approach, however, might not always pair with that philosophy. “NCLEX world still talks about otitis media – they’re not going to talk about principles of infection, they’re going to talk about an ear problem. So if you don’t relate those terms in your lecture, the students don’t make the connection,” Smith said. “We had to go back and refocus the way we taught ― not that we’re not using concepts, we are ― but we just had to show examples of how you can relate that concept to different diseases.”
This attention to minute detail reaped results in the April to September 2022 testing period. Within the NCLEX, passing performance for specific areas hovers between 49% and 50% of all possible questions that could be administered in a given category. Virginia Western graduates exceeded the benchmarks and percentages from similar associate degree programs, and all programs nationally, in every category, including 62% of the expected percentage correct for Pharmacologicial and Parenteral Therapies – compared with 57% for graduates of all other programs.
In almost all content areas, Virginia Western students taking the NCLEX from April to September 2022 placed in a higher national percentile rank than students taking the test from the same period in 2021.
Role of coaching
Previously, students received NCLEX prep materials, but the decision to use them was up to each person.
“I created the coaching role after 2021, because so few people completed the NCLEX prep,” Hayward said. Creating a student-faculty partnership that would endure after a student graduated became a multi-layered, intense effort.
“We want to walk hand in hand with students ― we can’t do their work, they can’t do ours, but there’s a synergy between those two roles for both sides to be successful,” said Hayward.
Students need to achieve licensure, and the program needs that to occur on the first attempt in order to meet Virginia Board of Nursing requirements. This is the mission. “Our success is that we fulfill our mission and that we meet the outcome regulated here, so we’re confident that we’ve been able to figure out what that is. My faculty have had to figure that out with a new curriculum in a pandemic, when everything was turned upside down for three years straight. The faculty had buy-in to maintain a really strong team, and the students and the faculty had buy-in to maintain a really strong relationship,” Hayward said.
All nursing faculty were engaged in five different areas of the curriculum that had shown student weaknesses, and four also took on coaching roles: Joe Nguyen, Darla Summers, Smith and Taylor.
Each person brought different strengths and ideas to the table, Nguyen said. “In one of our staff meetings, we said we really need to come up with a plan on how to get these students through. Lauren was so good at letting us work in an autonomous way, but also guiding us with what our strengths are,” he said.
He tapped the team approaches of his psychiatric nursing background, he said, in which the patient is part of the care team.
“There were some ups and downs, so I try to have a calm influence on folks. I guess it’s not so concrete, but it’s a ‘Hey, you know, let’s continue to work together and formulate relationships,'” Nguyen said. “With the students, in the summer, they’re no longer our students. So we had to keep a sense of a relationship going.”
Nguyen said they realized that for students, NCLEX preparation and content remediation “was fairly unstructured. What we determined was that they had gone through two years of very structured education, having guidance all along the way, because we advise the students very closely.” But when they graduated, as is common with nursing programs, “We were saying, ‘This is going to be the most important test of your life ― good luck! And let us know how you do.’ There’s a disconnect there.”
Solving that disconnect took some creativity.
“We started implementing a lot of standardized testing as we went along to identify areas that they were weak in,” Taylor said. “But it really didn’t come to fruition until last summer, when Lauren found funds to support the faculty working over the summer to coach specific students.”
Herbert-Ashton highlighted this interesting approach. “The other unique piece to this is that HEERF funding was utilized to support the coaches,” she said. The Higher Education Emergency Relief Fund provided funds during the pandemic to support student needs. “This is a great example of how HEERF funds were utilized.” Going forward, the coaching will be supported by the regular budget.
Implementing the coaching role
Coaching starts in the students’ fourth semester. Faculty members gave a lot of credit to Summers, who created an NCLEX test prep binder for students to help them stay on task. The binder included dates for the levels of preparatory testing they needed to complete.
“We use Kaplan resources, so over their two-year enrollment in the program, they take between 10,000 and 15,000 NCLEX-style questions,” said Hayward.
Familiarity with the testing style has an impact. “What I try to tell the students is that anxiety comes from feeling unprepared, a lot of times, when it comes to high-stakes testing. And when you feel more prepared, naturally you have less anxiety,” Nguyen said.
The NCLEX can last as long as five hours; the average time for Virginia Western students in this reporting period was 95 minutes, compared with 119 minutes from graduates of all programs. “If you’re prepared, when they throw a question at you, you think, ‘This one’s a hard one, I’ll get the next one.’ If you’re anxious, your mind goes to places that causes you to lose more focus,” Nguyen said. “Focus, structure, and guidance were the three things I saw that helped the students the most.”
Kara Gerenser, an RN and member of the 2022 Nursing Program cohort, agreed that this approach made a difference. “Graduation came with a lot of conflicting feelings. It was an enormous relief to be done with school but then we had to face the daunting task of prepping for the NCLEX.”
The preparation integrated in the program paid off. “I thought I would feel more nervous, but I believe our faculty really prepared us long before graduation. Mrs. Smith pushed our Kaplan resources from the first day of nursing school, and I think that helped me prepare the most. Each practice test I took or prep video I watched made me more and more confident that I had everything I needed to be successful,” Gerenser said.
Smith said she earned the nickname “Kathy Kaplan” in 2014. The program had Kaplan test preparation resources at the time, but amid a transition in faculty, it wasn’t being used. Still, it’s only in 2022 that the program started using this Kaplan graduate program with the NCLEX study plan.
Students have study modules that they can do on their own at home, videos, webinars and worksheets. “So Kaplan is a full product. It’s a product to use in school, it’s a product to complement, it’s a resource to help them learn, and Kaplan is also a testing avenue that helps the students compare themselves to their peers and to the nation,” Smith said. “And then we use this ― their final product, the NCLEX study plan, to help them pass their boards. So it’s an ongoing thing.”
Smith tracks data for how the cohort is succeeding in the progressive Kaplan testing program.
“Before, I’d call someone up and say, ‘Have you done this?’ and they’d say, ‘No, I’m too busy with work, no,’ but now, they’ve got target dates – they’ve got goals. It’s a very intense plan, and there’s something to do every week,” Smith said. “And now they have remediation, and we as faculty can look at their testing and see their strengths and weaknesses, and guide them to where they need to spend more of their time.”
She noted that graduates might be rushed and not see the forest for the trees. “We can go, ‘Oh, wow, you’re doing great on this, but you’re really bombing Pharm, you need to go spend more time there. Don’t spend so much time on Safety, you’ve got that. Or Basic Care, you need to go back and look at that,'” Smith said. “We keep charts and graphs on students, and the remediation, if they score low, we’ll give them an extra nudge.”
There are two types of tests in the Kaplan prep plan. There are trainer tests students do at home. Then there are standardized tests that have to be proctored, so they’re on campus.
Summers said she tells her students, “‘I know this feels like torture, but it will be worth it in the end.’ We do have their best interests at heart ― it’s not just busy work.”
Each student is assigned a faculty coach and is part of a group that keeps in touch before and after graduation with the Remind app. By communicating electronically, everyone receives updates and stays connected. Nguyen said students were inspired when other members of their cohort registered success.
“Each of our instructors really put their all into preparing us for the NCLEX,” Gerenser said. “The app we used was helpful because it was an easy way to stay connected and we got a notification every time someone in our group passed. I think that gave us the confidence boost we needed as we got closer and closer to our individual test dates.”
As students progress through the NCLEX prep plan, coaches determine when they have a “green light” to schedule their exam. Historically, graduates onboarding in their new jobs have faced pressure to test as quickly as possible so they can begin RN duties. Hayward recounted conversations with the employers that are the program’s partners. “You’re saying, based on your need to take care of the public, that they’re ready, and we really want that too, that’s what we’ve built them for, but they have to do this step successfully first, and if they’re not successful, it really impacts the education unit here.” The program’s Advisory Council, which consists mostly of employers, took this to heart, she said, and supported the NCLEX prep effort.
The standardized tests are the ones that are designed to mimic NCLEX, Smith said, and if any are below a certain level, “We tell them, ‘DO NOT take boards yet. You’re not ready.’ I know last year there were about three students we encouraged, do not take it yet. And I know one or two did change their dates. Because they did listen to what we said.”
The coaches jumped in to make sure students struggling in certain curriculum areas got help, even if it wasn’t a student assigned to them. “”We all have each other’s backs. Everyone’s willing to jump in and cover,” Summers said.
“To me it says a lot that you have faculty that are willing to work with students that’s not a mandatory course, side by side over the summer,” Summers said, noting that it’s an investment made by both parties. “Students are thankful for that, because we genuinely care about them.”
What’s next
Faculty members have prepared for another challenge ― changes in NCLEX.
“This year they’ve added different questions to the test,” Smith said. “So now we have the Next Gen, or the NGN questions, which we’ve been working on for two years.”
The questions are geared more toward application than memorization. “Now, we’re just changing the format of what the question looks like, so the students can be acclimated to that when they take NCLEX,” Smith said. “It’s not just a question with answers underneath ― it’s diagrams, it’s pictures, you’ve got a problem, you’ve got a hypothesis, you’ve got interventions, and you have to match everything up. It’s just a different way to test your knowledge.”
NCLEX has designed the NGN questions to use real-world case studies to measure a nurse’s ability to think more critically and make the right decisions.
Having new item-type questions does add pressure, Hayward said. “But on the other hand, it’s a way of thinking. There’s a clinical judgment measurement model that’s the new way of determining how well the student can make a decision. And so it’s not that they have knowledge and they read it, it’s that they can apply that knowledge and make a decision or a judgment ― and not just making a judgment, the correct one that will have the best outcome for the patient.”
Kaplan has incorporated NGN questions into their standardized testing, Smith said. “And we as faculty have incorporated it into our course content testing. So we’ve been preparing the students all along for that.”
Successful treatment
Nguyen said people have asked him at statewide meetings how the program improved their scores. “It’s already a sense of pride you have, not that we’re better, but we did something that worked, and there are more nurses because of that in the community,” he said. “You had the A-team. I guess it was kind of hard to lose, but it was still a lot of work. We learned a lot. And when I’m talking to these students this year, I tell them how the students bought in, and right now, we’re seeing them buying in, and their scores are higher.”
Taylor noted that, “At some point the students bought into it. And that caught fire and the competition and the ownership of, ‘I don’t want to be the one to let the program down’ became an integral part in their motivation ― almost more so than their personal interest and that ‘I want to do this for me because I want to pass.’ It was their connectivity, and that ‘I don’t want to let my cohort down, or my school down.’ The students had to do it, so ultimately the success belonged to them.”
Herbert-Ashton looks to the strength of the team. Hayward “created a very strong faculty team with shared governance,” Herbert-Ashton said, crediting Hayward’s can-do spirit. “She’s always talking about shared governance, and that this is a partnership. And she tells the students that we are in a partnership for the next two years. You are a partner, and you are responsible ― we’ll do our part, but you need to do your part.”
Each faculty member highlighted the team approach.
“It is the best team I’ve ever worked with,” Nguyen said. “It’s not one person, it’s not one entity.”
Success wasn’t always apparent. “Sometimes we couldn’t see it ― we couldn’t see the buy-in, or we got really nervous,” he said. Were students holding up their end of the bargain? “But we figured out, just through texting or talking with one another, ‘Hey, could you help me out with this student, I’m having a hard time communicating with them,’ and it seemed to work.” Students said, “‘Oh, Mr. Nguyen’s still on me, oh, Ms. Smith’s still on me, OK,’ they felt our urgency as well, and that helped a lot. So it’s a cliché, but it’s just a team effort.”
The students were part of the team, he said, and it all had to come together. “The credit goes to everybody.”
Now, a year later, Gerenser is an RN in the operating room at Carilion Roanoke Memorial Hospital. “I honestly wouldn’t be where I am today without every single one of the faculty members of the nursing program or the people in my cohort,” she said. “Starting nursing school in the middle of a pandemic was extremely difficult and stressful and a little bit crazy. But we weathered the storm together and came out stronger because of it. It’s amazing to see these people living their dreams as nurses, and I am endlessly thankful that I got to go on this journey with them.”
