Why Did They Fail The Test



When a GN Doesn’t Become an RN: How the Staff Educator Can Help

Susan G. Poorman

Melissa L. Mastorovich

Cheryl A. Webb

Journal for Nurses in Staff Development

Jan-Feb

Volume 18 Number 1

Pages 14 - 19

With national NCLEX pass rates declining, nursing orientation costs increasing, and the nursing shortage escalating, the trauma that occurs when a graduate nurse fails the NCLEX can be felt reverberating throughout the clinical units. NCLEX failure not only adversely affects the individual who fails but can have a profound effect on staff workload and morale. Staff educators are in a unique position to help the new graduate who has been unsuccessful in passing the NCLEX; however, they may be unsure of how to approach the situation. The authors present several strategies that the staff educator will find easy to implement to help these graduates.

When graduate nurses fail the National Council Licensure Exam (NCLEX), both the graduates as well as the personnel on their assigned units can feel devastating results. In the middle of a costly orientation, graduates have to be removed from their positions as nurses. This leaves the graduates feeling degraded and the units understaffed. It also poses a financial burden to the institution as orientation for new graduates can often range from $20,000 to $50,000 ( Messmer, Abelliera, & Erb, 1995 ).

Staff educators may often be able to help the graduate nurse (GN) who has failed the NCLEX; however, they may be unsure of how to approach the problem. This article discusses several strategies that have been found to be effective in such situations.

Confronting the Failure:

Natalie, a newly hired GN, has been working on 3-South, a medical unit, for the past month. The staff on the unit genuinely like Natalie and believe that she will be an asset to the staff. Today, Natalie arrives at work and seems different to her colleagues. She is quiet and almost sullen. When staff members ask Natalie if there is anything wrong, she explains that she has failed the NCLEX and cannot be a nurse. Throughout the day, Natalie’s mood becomes increasingly sad, almost agitated. Natalie is resentful that she cannot keep this secret from her coworkers. Throughout the day she worries about what will happen when the rest of the staff find out.

When new graduates first learn that they have failed the NCLEX, they are often flooded with a variety of negative emotions. They not only fear that others will learn of their failure, but often experience catastrophic fantasies about what others will think of them and their abilities. They sometimes feel guilty about disappointing others. They can become angry and may frequently ask, “Why did this have to happen to me?” They are usually sad over losing their positions as nurses and are confused about what to do next ( Poorman & Webb, 2000 ).

One of the most dangerous reactions experienced by the GN in this type of situation is denial. Denial can be exhibited in behaviors such as refusing to tell anyone what has happened, pretending not to be upset by the failure, and, most dangerously, denying the gravity of the problem. Denial can be so harmful that it can keep the individual from seeking help. Graduates who have a reaction of denial and avoidance and then retake the test without obtaining appropriate help frequently put themselves at risk for refailing the test. The complexity of their problem increases each time they fail the NCLEX. As a result, helping these individuals becomes more difficult and complicated. Recent statistics indicate that graduates who fail the NCLEX have approximately a 50% chance of passing the exam on future attempts ( National Council of State Boards of Nursing, 2001 ).

One of the first ways staff educators can help the new graduates is by approaching them (privately) to address the issue. The staff educator who approaches the graduates conveys the message that it is okay to discuss their feelings. The staff educator can gently guide graduates to the point where they can acknowledge the problem and want to get help. The following conversation between a staff educator and a GN demonstrates this point.

Staff Educator: “I understand that you failed the NCLEX.”

GN: “Yes, I did.”

Staff Educator: “How are you doing? How are you feeling about this?”

GN: “Well, I guess I am okay, better than I was 3 days ago when I found out.”

Staff Educator: “So you have had some time to think about it? What are your plans for getting ready to retake the exam?”

GN: “I don’t know yet. I guess that I will just study harder and review all of my notes from nursing school.”

Staff Educator: “Why do you think you failed the test?”

GN: “I don’t know; I guess I just didn’t know enough.”

Staff Educator: “Sounds like you aren’t sure why you failed; it seems as though we need to start there. I’d like to help you. Let’s try to find out what your testing problems are and then see what we can do to help you fix them.”

This approach by the staff educator serves several purposes; first, it gently nudges the graduate out of the denial phase; second, it offers the graduate both support (“I’d like to help you.”) and the structure of a place to start (“Let’s find out why you failed.”). The staff educator then offers to meet with the GN on a regular basis to help identify and offer guidance in addressing problem areas. If several nurses in the hospital have been unsuccessful on the NCLEX, forming a small group may be helpful. Knowing others have failed the test keeps graduates from feeling alone and shameful. In small groups, graduates find it easier to discuss their problems and often find support from each other.

Why Did They Fail the Test?

The first factor that needs to be assessed when beginning to help graduates who have failed the NCLEX is to ask, “Why did they fail?” GNs fail the exam for various reasons. In order to individualize the approach, it is imperative to examine this issue thoroughly.

There are several common reasons why graduates fail the NCLEX. The first reason is a knowledge deficit. This is the easiest problem to identify, and new graduates usually believe that this is the only reason that they failed the test. Knowledge deficits can be identified by the graduate’s inability to give any reasonable explanation for the right and wrong answers on practice questions. They also consistently have very low percentage scores on their practice tests.

Graduates may also fail because of testing or reasoning errors. These types of errors are evident when the GN is lacking the test-taking or test-thinking skills necessary to reason through the question and arrive at the correct answer. An example of a reasoning error is adding information to the question that is not directly related or necessary. Another example of a reasoning error occurs when graduates do not understand what the question is asking and they select the wrong answer. In this example, the problem is not lack of information but a misunderstanding of the information that is being requested.

A third reason for NCLEX failure is test anxiety. Some individuals are well aware of their test anxiety and understand how it has unfolded throughout their lives; others are not as cognizant of its presence or its effect on their test-taking behavior. Test anxiety can be seen in a variety of behaviors; for example, individuals may incorrectly answer the majority of the questions at the beginning of the test because they are unable to control their test anxiety until the latter half of the test. These individuals experience an inability to calm themselves quickly enough. This type of anxiety can also be the culprit when the GN repeatedly misreads a question, misses important words in a question, or has difficulty concentrating or remembering known information during the test.

Test anxiety can also contribute to a dangerous testing symptom called clumping. Basically, clumping occurs when the individual incorrectly answers several consecutive questions. For example, the GN might miss questions 17, 18, 19, and 20 on a practice test. When graduates miss several unrelated questions consecutively, it is often the result of distorted thinking, not a knowledge deficit.

Strategies for Helping the Graduate Nurse:

Knowledge Deficits

When helping the GN prepare to retake the NCLEX it is best to start by eliminating the knowledge deficits. Most individuals have areas of knowledge weakness; however, this can vary greatly from one individual to the next. Assessing a knowledge deficit starts by asking the graduate to complete practice sets of questions from several different NCLEX question books on a daily basis. There are many books that contain practice NCLEX questions; thus, choosing the proper resource text may be difficult. Several guidelines may be helpful.

First, one book will not be enough. Completing a multitude of questions can enhance the graduate’s problem-solving skills. Using several NCLEX books will afford the GN much needed practice in answering questions in addition to what the staff educator can offer.

Second, the questions should have been tested on groups of graduate nurses to meet acceptable testing standards. Texts containing questions that are tested often include a statement attesting to this fact. The book should also have a variety of questions and, most importantly, detailed rationale for each question. The rationale should state why the correct answers are right and the distracters are wrong. This will aid the GN in developing better reasoning and problem-solving skills.

Following the purchase of several NCLEX textbooks, ask the graduates to use a notebook to record their answers rather than writing the answers directly in the books. Suggest using a different colored pen to mark the wrong answers and indicate the content area of the missed questions. This will provide both the GN and the staff educator with ongoing visual assessment information. After the GN completes approximately 7 days of practice questions, the staff educator should meet with the GN. When the GN and staff educator review the answer sheets collectively, they will begin to see patterns of knowledge deficits beginning to emerge.

For example, Natalie incorrectly answers five or six medical surgical questions out of each set of practice questions; however, she rarely misses questions in specialty areas such as pediatric, obstetric, or psychiatric nursing. Clearly, her area of knowledge deficit is medical surgical nursing. However, the amount of material pertaining to medical surgical nursing is substantial. To ask a GN to review all of medical surgical content is a daunting, often overwhelming task. In an attempt to condense the task into something more reasonable, ask the GN to complete several practice sessions of medical surgical questions. Again, patterns will likely emerge through visual assessment.

When Natalie completes only medical surgical questions, she repeatedly misses questions in the areas of cardiac and endocrine nursing. She occasionally misses questions about neurological nursing, but rarely do any other content areas emerge as deficits. Her task is now significantly more manageable. Instead of reviewing all medical surgical content, encourage Natalie to review one specific area of knowledge deficit at one time. For example, she can begin by reviewing the chapter on cardiac nursing in her medical surgical textbook, and can complete the cardiac NCLEX practice questions to further assess whether her knowledge deficit in cardiac nursing is decreasing. When satisfied that Natalie is competent in this area, the staff educator can work toward eliminating Natalie’s knowledge deficit of endocrine nursing similarly. By using this process, GNs will be able to systematically reduce areas of knowledge deficit. They will begin to feel a measure of control over the NCLEX preparation process and can usually realize that they may have incorrectly answered test questions for reasons other than lack of knowledge.

Testing and Reasoning Errors

One of the best ways to help the GN with testing and reasoning errors is to use the metacognitive strategy of “think out loud.” This technique promotes critical thinking through active learning and triggering of the cognitive process ( Youngblood & Beitz, 2001 ). This technique is effective and easy to implement. The staff educator simply asks the graduates to “think out loud” by stating how they formulated the answer to the practice questions. For example, the staff educator might say, “Natalie, think out loud for me. How did you decide on option B as the correct answer to this question?” When the staff educator hears the reasoning, it is frequently easy to recognize the errors and repeated patterns. Here it is often helpful to ask the GNs questions to guide them in discovering their own erroneous thinking. For example, the staff educator reviews the following question (From Poorman, Webb, Mastorovich, & Molcan, 1999 ) with a GN:

A client with a basilar skull fracture is suspected of having cerebrospinal fluid (CSF) rhinorrhea when she complains of bloody drainage from her right nare. Which of the following test results would confirm the nurse’s suspicion?

A: Drainage tests positive for glucose.

B: Drainage yields a positive guaiac test.

C: Presence of the “halo” sign.

D: Presence of the Battle’s sign.

The GN chooses option A. The following conversation between the staff educator and the GN occurs.

Staff Educator: “You picked option A. You wanted to test for glucose. Think out loud for me. How did you decide on this option?”

GN: “Well, I was thinking that CSF contains glucose, so I should test for glucose.”

Staff Educator: “What do you know about the drainage?”

GN: “It is bloody.”

Staff Educator: “Does blood contain glucose?”

GN: “Yes. So if both CSF and blood contain glucose, I wouldn’t know which one would be making the test positive.”

Staff Educator: “Right. So it can’t be option A. Now what do you think?”

GN: “Well, I know that a guaiac test is for blood so that can’t be the answer. Battle’s sign is a bruise near the ear, and that wouldn’t tell me what type of drainage I would have. The answer must be C, a ‘halo’ sign.”

Staff Educator: “Exactly. If the drainage is CSF, it should cause a circle with a pinkish center surrounded by a yellowish ring or halo. The yellowish ring is CSF.”

This method is also helpful when students add information to the situation that creates an error in their thinking process. For example, a GN chooses option A for the following question (From Poorman, Webb, Mastorovich, & Molcan, 1999 ):

After receiving verbal report at 3 p.m., which of the following clients should be assessed initially by the nurse?

A: A 46-year-old who returned from an abdominal hysterectomy at 12:00 p.m.

B: An elderly client who is confused and requires a waist restraint.

C: A 36-year-old postoperative craniotomy client who has had a urine output of 360 cc in the last 2 hours.

D: A client with insulin-dependent diabetes mellitus (IDDM) who is taking prednisone (Deltasone) for her rheumatoid arthritis and has a glucose level of 200.

The staff educator might intervene in the following manner:

Staff Educator: “How did you decide that the client in option A should be seen first?”

GN: “Well, I was thinking, she could be hemorrhaging after surgery so I better check her first.”

Staff Educator: “How do you know?”

GN: “I guess I made that up.”

Staff Educator: “Do you have any evidence she is bleeding?”

GN: “No. I just thought hemorrhage is a major complication of an abdominal hysterectomy.”

Staff Educator: “What else do you know about the clients in the other options?”

GN: “I know that the client in option B would not be a priority because even though he is confused, he is safe. I also know that a blood glucose level of 200 is a little high, but would be expected if the client is on prednisone and also has IDDM. Even if the client needed some insulin, as long as I gave it within one-half hour it would be okay. So the answer must be C.”

Staff Educator: “Yes. Do you know why?”

GN: “Well, 360 cc in only 2 hours is a lot. I know that diabetes insipidis is a complication of a craniotomy, so I better see him first to see if he has any other symptoms.”

Staff Educator: “So, in option C you have evidence there is something wrong, whereas in option A there is only a possibility that something might be wrong.”

Test Anxiety:

Test anxiety encompasses both the emotional feeling of anxiety and worrisome negative thinking ( Johnson, 1997 ). The more the graduates experience negative thoughts or cognitions about themselves and their test-taking abilities, the more likely they are to experience test anxiety. Thoughts such as, “I am never going to get these questions right,” “I am too stupid; everyone else knows the answer but me,” and “My life will be over if I don’t pass this exam,” can be extremely detrimental to the ability to focus and concentrate during an exam. Techniques that are helpful in decreasing the effects of destructive thoughts include cognitive restructuring and thought stopping. An additional technique, progressive relaxation, can help GNs control emotional tensions related to test anxiety.

Cognitive restructuring is a method of assessing thoughts to determine their validity. Negative thoughts, as identified above, contribute to negative emotions (e.g., anxiety) that result in negative behavior (e.g., inability to concentrate, low test scores) ( Northam, 2000 ; Sapp, 1999 ; Zeidner, 1998 ). Changing the thoughts would decrease GNs’ anxieties and increase their ability to concentrate, producing higher test scores. In the above example, the negative thoughts can be examined by asking three questions:

1. “Is it really true (that I’ll never answer these questions correct)?”

2. “What evidence do I have to support this thought? (I’m having trouble, but I’ve answered other test questions right; I can get some of these right, too.)”

3. “What is the worst that can happen? (I’ll fail the NCLEX. I’ll be sad. If I have to retake the test, I will find out why I failed and do better the next time.)”

Thought evaluation often mobilizes graduates by helping them realize the lack of evidence for their thinking or ways they can plan to overcome the problem.

A simplified explanation of this technique is that the individual is taught to develop an increased awareness of negative thoughts and is then helped to neutralize them; thereby decreasing the impact of the negativity. The staff educator can help graduates assess their negative cognitions related to the upcoming retake of the NCLEX and examine their validity. For example:

GN: “When I think about taking that test again, I think, if I don’t pass this time everyone will know for sure that I am stupid.”

Staff Educator: “What evidence do you have that everyone will think you are stupid?”

Asking GNs to maintain a daily log of thoughts that occur to them about the test will help increase their awareness of how frequently these thoughts occur and how potentially debilitating they can be. Seeing the negative thoughts on paper gives the graduates an opportunity to “reality test” their thoughts by asking just how true the statements are. The staff educator can help graduates change the distorted thoughts to ones that are less emotionally charged.

The second technique for decreasing distorted negative thoughts is a technique known as thought stopping. This technique can momentarily stop the stream of irrational thinking. When graduates begin to experience negative thoughts, a ruminating series of negative cognitions often results. These thoughts become increasingly distorted and displace the graduate’s focus from accurately answering the questions. The technique of thought stopping provides graduates with a tool to begin to control negative thoughts and to redirect attention and focus on the content of the practice questions.

A variety of methods are available to implement the technique of thought stopping. A stimulus such as clapping hands, snapping fingers, or lightly twisting or snapping a rubber band worn loosely on the wrist while telling oneself (silently) to stop can interrupt the stream of negative thoughts ( Davis, Eshelman, & McKay, 2000 ). Graduates have often found that using a rubber band as a stimulus is a practical and easy-to-learn way to use this technique. For example, when Natalie attempts to answer a question she cannot answer, she may begin thinking “Oh no, I can never remember the difference between Addison’s and Cushing’s disease. Is it too much cortisol or not enough? I know moon face goes with one of them. Why can’t I remember this? I’m too stupid to be a nurse. I don’t know anything. Stop. You know this information. Think about what this question is asking me?”

This simple technique can greatly enhance test performance. However, it is a behavioral technique; therefore, it requires continuous practice to gain mastery. Thus, graduates are encouraged to wear the rubber band throughout the day and use it for all types of irrational thinking. Further, while practicing this technique it is important that graduates follow-up thought stopping with an action phrase such as “right now I need to focus on...” For example, a graduate might be caring for a patient when one of her well-meaning friends asks, “Have you been studying for the NCLEX? Do you think you are ready?” Such comments can begin a stream of irrational thoughts that must be consciously stopped: “I think I’m ready; I hope I’m ready. What if I don’t pass? I was fine until you brought it up! Stop. I am preparing and working on this every day, but right now I need to finish giving this client a bath.”

A long-standing strategy for decreasing test anxiety is progressive relaxation. Progressive relaxation is based on the premise that the body responds to stressful situations, such as preparing to take or retake the NCLEX, by producing muscle tension. In progressive relaxation, each muscle group is alternately tensed and relaxed so that the muscles learn the difference between the two sensations. The body cannot simultaneously feel both relaxation and muscle tension. Therefore, graduates who learn how to relax their bodies in stressful situations will feel the relaxation, not the tension. This allows the GN to focus on taking the test instead of feeling tension. However, progressive relaxation is not a quick fix for decreasing test anxiety. It is a behavioral technique that must be practiced over time. The effect of progressive relaxation is gradual. Generally, it is recommended that a progressive relaxation exercise be completed twice daily for at least 4 weeks for optimal results ( Bourne, 2000 ; Sapp, 1999 ). Several self-help books are available for individuals with mild or infrequent test anxiety.

Knowing When to Refer:

For the graduate, preparing to retake the NCLEX can be a very stressful experience. When the test anxiety does not decrease from these simple interventions, referral to an anxiety expert (preferably a test-anxiety expert) should be seriously considered. If the staff educator identifies the GN as experiencing feelings of depression and sadness that surpass feeling disappointed and embarrassed by the failure, or if it becomes obvious that many nonacademic factors are involved in the graduate’s inability to succeed, it is then appropriate to make a referral to a mental health nurse for assessment. It is also appropriate for staff educators to conduct a suicidal assessment by simply sharing what they are observing and by asking about suicidal thoughts. If the GN is having suicidal thoughts, the staff educator must make an immediate referral to a psychiatric professional.

Summary:

Failing the NCLEX can be an overwhelming and frightening experience for the GN. This article provides several strategies to assist the staff educator in helping the GN. Assessment of factors that contribute to NCLEX failure are presented. Further, specific interventions to address each problem are discussed. Support offered by the staff educator can aid the GN in mobilizing efforts to retake the exam. When this help results in NCLEX success, graduates can then be placed where they are needed the most, at the bedside.

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