An Investigation Of Student Use Of PrepU NCLEX 5,000 And NCLEX-PN . - LWW

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L I P P I N C O T T F O R L I F E White Paper An Investigation of Student Use of PrepU NCLEX 5,000 and NCLEX-PN Success by Dr. Julia Phelan, National Center for Research on Evaluation, Standards, and Student Testing, University of California-Los Angeles S U M M A RY / C O N C L U S I O N S Students who used prepU during their final semester at nursing school had a 94.8% pass rate. Students who used prepU both during their course and afterwards to study for the NCLEX had a median of 85 questions on the NCLEX (average of 101) compared to the national average of 113 (for those students who reported question data). Average prepU mastery level for students who used prepU and passed the NCLEX was 4.75. Usage of prepU leads to demonstrated ability to correctly answer more difficult questions; mastery of the content improves. This increased content mastery and performance is measured by the prepU Mastery Level. Introduction Combining a formative assessment tool for instructors and an online quizzing and learning environment for students, prepU brings together best practices in learning, technology and assessment to provide a unique adaptive quizzing tool for students and instructors. Research supports the idea that retrieval practice (the process of retrieving information from your memory) plays a significant role in long-term retention and learning (Karpicke & Blunt, 2011; Roediger & Butler, 2011). The phenomenon has been studied in the test-taking context and findings provide overwhelming support to the fact that retrieval practice leads to a higher long-term retention of material than simply studying using more passive techniques. As Roediger and Butler (2011) state: “ testing, which is commonly conceptualized as an assessment tool, can be used as a learning tool as well” (p. 6). prepU provides opportunities for students to reap the benefits of retrieval practice and frequent quizzing during their coursework and also while preparing for high-stakes exams. To help us better understand the use and impact of prepU we created the Wolters Kluwer/ prepU Efficacy Project.

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success What is the Wolters Kluwer/prepU Efficacy Project? The Efficacy Project is a multi-pronged research approach designed to: gather qualitative and quantitative information on student and instructor usage of prepU explore the relationships between student achievement, prepU usage and content mastery help determine the efficacy and impact of using prepU in nursing and NCLEX preparation courses explore different use cases of prepU analyze the significance and accuracy of predictions based on prepU variables and student performance outcomes The following summarizes findings from an exploratory study of students who had access to prepU during their nursing program (practical/vocational nursing). This study is a follow-up to a broader set of studies in which we are investigating prepU usage in students preparing for the NCLEX-RN. Within those studies we have explored students’ usage of prepU as they prepared to sit for the NCLEX and also investigated the relationship between prepU usage, content mastery and students’ ultimate success on the NCLEX exam (see Phelan, 2012). About prepU prepU is an adaptive quizzing system designed to provide students with an environment in which they can effectively and efficiently practice and master course content. The prepU platform is used in numerous course topics across the nursing curriculum, including NCLEX preparation and review courses. Adaptive testing is efficient and helps focus student learning on the right content. Within the adaptive quizzing area of prepU, a student’s ability level is determined and continuously updated by their responses to calibrated items with known difficulty parameters. As students answer questions in PrepU they achieve a “Mastery Level” on topics they have taken quizzes in. A Mastery Level is essentially a measure of the average difficulty level of the questions a student answers correctly. As a student answers more difficult questions correctly, s/he is given even more challenging questions on future quizzes. If these questions are answered correctly— allowing the student to demonstrate greater and greater mastery on course concepts, the student moves up in Mastery Level. 2 Transforming Nursing Education and Nursing Practice Together Within prepU, the questions on a quiz are specifically chosen to motivate the student, and to maximize their potential in the most efficient way. If students all see the same set of questions, many of those questions will be too easy or too difficult. In either case, the student will not be as motivated to practice and learn. prepU is not designed to push students through the system as quickly as possible, but rather to motivate and help students master the content they need to learn. prepU provides an environment in which students can practice and improve and can compare their performance to thousands of other prepU users across the country. Not only does prepU harness the power and efficiency of adaptive testing models, it also exemplifies many of the best practices in learning as evidenced by research on retrieval practice. Retrieval practice essentially describes the process of retrieving information from your memory. The phenomenon has been studied in the test-taking context with the goal of determining its role in long-term retention and learning (Roediger & Butler, 2010). About the NCLEX-PN To protect the public, boards of nursing and regulatory bodies require students seeking to obtain a license to practice nursing to pass an exam. This exam measures the competencies needed to perform safely and effectively as an entry-level nurse. The NCSBN has two licensure exams—the NCLEX-RN for registered nurses, and the NCLEX-PN for practical/vocational nurses. The practical/vocational nurse uses “specialized knowledge and skills which meet the health needs of people in a variety of settings under the direction of qualified health professionals” (NCSBN, 2014; NFLPN, 2003). The practical/ vocational nurse engages in clinical problemsolving processes to work with relevant health care data, assist in the identification of the health needs/problems throughout the client’s life span and contribute to the interdisciplinary team in a variety of settings (NCSBN, 2014). The NCLEX-PN test plan is organized into four client needs categories, with a pre-determined percentage of items assigned to each category. The NCLEX-PN exam is a variable length CAT anywhere from 85 to 205 items long. The time limit for the exam is five hours (maximum), and the length of the exam is determined by the candidate’s responses to the items. After the minimum number of items (85) has been answered, testing stops when either a) the candidate’s ability is determined to be either above or below the passing standard with 95% certainty, or b) the examination maximum number of items has been answered, or c) the time limit has been reached. In April 2011, the standard increased to –0.27 logits. It is important to note that the RN and PN standards are not directly comparable because they are based on different item pools and different scopes of practice.

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Pass rates for 2014 so far are (for first time, U.S educated students) 82.59%. In 2013 the overall pass rate was 84.63%. There about 1/3 as many students taking the NCLEX-PN as the NCLEX-RN (in 2013 58,575 vs. 163, 001). Exam statistics for 2012 and 2013 are available from the NCSBN (see Table 1 below). Table 1: Summary statistics for the NCLEX-PN (2012 and 2013) (NCSBN, 2014) Statistics across the two years shown in Table 1 are very similar (and in many cases identical) in terms of number of questions answered, time taken and so on. Sample and Design Results Given our interest in the relationship between prepU usage and NCLEX outcome, we first analyzed data for the 161 students who had taken the NCLEX exam (as of August 2014). Table 2 shows the reported NCLEX outcomes for the 161 test takers. Of the 161 students, 154 (95.7%) indicated if they had passed the NCLEX. Seven students left this question blank. Of the 154 students who reported their outcome, 94.8% passed and 5.2% did not. We asked students to report the number of questions they answered on their exam (prior to it stopping). Not all students answered this question; of the 146 students who indicated they passed the exam, 133 reported their question number, as did three of the students who did not pass. These data can be seen in Figure 1. In June, 2014, a survey was deployed to 1,000 prepU, NCLEX 5,000 users. The survey contained 11 questions pertaining to graduation date, NCLEX test date, number of NCLEX questions answered, NCLEX result, and use of PrepU to help prepare for the NCLEX. The number of respondents to the survey was 312/1000 31.2%. This response rate is slightly higher than that reported in the literature. Kaplowitz, Hadlock, and Levine (2004) reported a 20.7% response rate to email-deployed surveys, and Sheehan (2006) reported an average response rate to email, surveys of 24%. Survey data provided information on perception and opinion of prepU as a NCLEX preparation tool as well as information on other products used to prepare for the exam and related opinions. For all students who used prepU, we collected usage and mastery information from the system. All prepU data collected was cumulative. We employed a retrospective, descriptive analysis to the data to explore the relationship between use of prepU and self-reported score on the NCLEX exam. This analysis provided information on how PrepU usage related to NCLEX pass rate and/or number of questions answered. We also explored feedback provided by those students who reported using PrepU to prepare for the NCLEX exam, and provided details on their experiences doing so. 3 Transforming Nursing Education and Nursing Practice Together Figure 1: Distribution of number of NCLEX questions answered For the 136 students who reported their NCLEX question number, the average number was 101.62 (SD 39.58). A more informative

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success measure of question number in this group is the median, which was 85 and almost 50% of the sample reported answering 85 questions (the minimum number of questions for the NCLEX-PN). Just fewer than 78% of the sample answered 92 questions or fewer. The three students who did not pass the exam and who reported their question number answered 182, 78, and 85 questions. prepU Usage and Mastery prepU Usage and Mastery data were analyzed for the NCLEX group. Overall usage is shown in Table 3. Figure 2: Distribution of Quizzing Questions One student did not use the prepU and so was removed. Overall usage and ML is shown for the students who used prepU (N 160). The variance in number of questions answered was large (SD 1683.29). The median number of questions answered was 1335.5, which in a sample such as this is a better measure than the mean. Figure 2 below shows the distribution of questions answered across the group. As we often see in other samples, there is a long tail to the right in the distribution indicating some students have very high usage, but there is a smaller overall pattern (as seen by the median of 1335). 4 Transforming Nursing Education and Nursing Practice Together Given the distribution of questions and the large variance, we divided the students into question groups (based on quartile cut offs). Within each quartile group, the ML increased along with the number of questions answered. As the number of questions answered increased, so did the ML. Thus, as we often see, students are better able to answer more difficult questions the more practice they have.

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success A Pearson product-moment correlation coefficient was computed to further assess the relationship between prepU Mastery Level and all other prepU usage variables. There were significant positive correlations between all variables (see Table 6). had used it once or twice actually had answered an average of 276 quizzes and logged in an average of 88.57 times. The reported usage is shown in Table 8. 2. Use of Other NCLEX Preparation Resources Comparing Usage Based on NCLEX Outcome prepU usage was compared between those who passed and did not pass the NCLEX. Although there were differences, none of them were significant. Table 7 shows comparative data for these two groups. The difference in size of the two groups makes the comparative analyses here less meaningful (there are only 8 students in the group of students who did not pass the NCLEX exam). For the 160 students in the sample, we explored usage of other NCLEX prep materials/programs (based on the responses to two of the survey questions). The questions asked students to first indicate if they had used other products, and then to name the other products they had used (if any). The most frequently-cited alternative study method was prepU (for other subject areas) which was used by 48.4% of students. Kaplan was used by 21% of students and ATI by 36% (see Table 10). Survey Response Data 1. Frequency of Use One of the student survey questions asked students to report on how often they used prepU. Actual usage (for those students reporting little or no usage) did not match well with their reported usage. For example, the two students who said they had never used prepU, answered an average of 120 quizzes and those who responded they 5 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success 3. Level of Preparation 4. Comparison to Other Tools Used to Prepare Students were asked to rate how well prepU NCLEX 5,000 helped in preparation for the actual NCLEX. Responses were coded in the following way: Students were asked to compare the NCLEX 5,000 to other preparation products used. Responses were coded in the following way: Excellent preparation 5 Good preparation 4 Fair preparation 3 Poor preparation 2 Did not use 1 Response frequencies are shown in Figure 3. Of the 160 students who took the NCLEX, 35% (N 56) rated their preparation using prepU NCLEX 5,000 as excellent, 45% (N 72) rated it as good preparation, 13.1% (N 21) rated it as fair, and the remaining 6.9% rated it as poor, that they did not use it, or they skipped the question entirely. Significantly better 5 Slightly better 4 About the same 3 Slightly worse 2 Significantly worse 1 I did not use products other than NCLEX 5,000 0 Response frequencies are shown in Figure 4. 20% of the group liked the NCLEX 5,000 significantly better than other preparation products used, 23.1% thought it was slightly better, 38.8% rated it about the same as other products, 6.3% slightly worse, and 3.1% significantly worse. 8.1% of the group reported to only have used the NCLEX 5,000. Figure 3: Survey Response Frequencies for Rating NCLEX Preparation Figure 4: Survey Response Frequencies for Comparing Against Other Products 6 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success If we consider only those who used prepU NCLEX 5,000 as well as other resources, we see the following: Figure 5: Survey Response Frequencies for Comparing Against Other Products (Users only) So about 89% of students rated the NCLEX 5,000 as about the same or better when comparing preparation tools. And 47.2% rated it as slightly better, or significantly better. Binomial Logistic Regression Analyses A binomial logistic regression analyses would typically be conducted to determine the predictability of prepU usage and mastery variables on NCLEX outcome. The number of students who failed the NCLEX (N 8) is not sufficient enough to allow us to conduct this analysis. The minimum number in each group is 15. Survey Data: Additional Information Survey data for the total group of students who responded to the survey can be found in Appendix A. We will follow up with the group of students as more of them take the NCLEX-PN. Limitations The data reported above are a subset of data from a survey sent to 1,000 students who had access to prepU NCLEX 5,000. We had a relatively high response rate (31.2%) although not all of the respondents had taken the NCLEX-PN at the time they responded. Thus, our final sample used for analysis was 160 students (16% of the sample). 7 Transforming Nursing Education and Nursing Practice Together Although, we did not exclude students for any reason except whether or not they had taken the NCLEX at the time they submitted the survey. Limitations thus exist in terms of the amount of complete data available for each student, and the self-report nature of reporting of NCLEX pass rates. These limitations, however, are not unique in the nursing domain and in similar studies we reviewed sample sizes tend to be limited. Indeed, in most of the senior-level nursing courses included in the broader efficacy study, class size tends to be between 18-25 students and larger sample sizes are less common. Furthermore in studies looking at similar student outcomes, NCLEX success data were self-reported via surveys sent directly to schools. Generalizability of the findings may also be affected by potential differences in schools, curricula, content of courses, grading practices, student demographics and so on. We also don’t have information (from the student survey) regarding implementation of prepU and we know this can vary quite significantly between schools. We report some correlational analyses in the report above and important to keep in mind is that correlations are measuring the strength and direction of a relationship between two continuous variables—for example number of questions answered in prepU and Mastery Level (measured from 1-8). What we are exploring with a correlation is the existence of a relationship between two variables, but we cannot make causal inferences based on the results. There are of course many unknowns in projects such as this one: Individual differences between students play a large role in student performance and there are not always pre/post data against which to measure growth or change. In addition, as any instructor will tell you, there will always be students who achieve a high grade without seeming to put in much effort and those who apply themselves with serious effort who somehow don’t make the grade. Many educational interventions seek to focus on those students between the two extremes; in other words, those who are perhaps within reach of achieving something more, if only they had some more motivation or extra help. We continue to collect more data and design and implement additional studies in ongoing efforts to address the above issues and further explore the efficacy of prepU with a larger representative sample. Conclusions, Implications and Next Steps This descriptive study reflects data from ongoing efforts to understand use of adaptive quizzing methods to help prepare students for the NCLEX. Within the sample of students included, adaptive quizzing was shown to be an effective tool to prepare for their licensure exam and increased use was associated with increased content mastery. The more quizzing activity, the higher the students’ ML; this reflects a greater understanding of relevant content.

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success When exploring the impact of prepU usage on NCLEX outcome, one cannot draw many firm conclusions about the comparative value as the majority of students in the sample pass the licensing exam on the first try. Indeed, in this sample, there were so few students who did not pass the exam, that we were not able to run any regression analyses to explore predictability of prepU usage and mastery variables on NCLEX outcome. The nature of the NCLEX data (pass/fail) and the high percentage of study students passing the NCLEX renders analysis complex as there is little variation in student outcomes. Operating within these constraints we explored the relationship between usage of prepU and subsequent success on the NCLEX. For 2013, the national pass rate for the NCLEX-PN is 84.63%, and in the study sample students had a 94.8% pass rate. The NCLEX-PN is a pass/fail exam—with no reported numerical score. The only variable a student does know after taking the test is how many questions they answered before a decision was made. We were interested in comparing the number of NCLEX questions each student answered to final NCLEX outcome and prepU usage. A reasonable hypothesis is that well-prepared students are more likely to pass the exam with fewer questions than are less well-prepared students, although there are no known empirical studies supporting this idea. Conversely, however, a poorly-prepared student may also likely see the minimum number of questions as the computer will recognize they are not answering enough questions (and those at certain difficulties) correctly. The median number of questions answered was 85 and the average 101. In 2013 (and 2012) the average number of questions answered (nationwide) was 113. Thus, students in the sample were passing the NCLEX after seeing fewer questions than the national average. And the difference is more marked if we look at the median number (which is more appropriate given the distribution). prepU ML has been shown in many of our other studies to significantly predict course outcomes such as number of total course points, or final grade (see Phelan & Smith, 2012; Phelan & Orm, 2012; Phelan and Phelan, 2012; Phelan & Phelan, 2011). In the current study we analyzed the relationship between the average ML of those students who passed the NCLEX and also used prepU in a meaningful way. Those students who passed the NCLEX and used prepU had an average ML of 4.75 and ML was significantly positively correlated with the number of questions students answered in prepU. The study discussed here reflects early efforts to better understand student use of prepU to help prepare for the NCLEX-PN and also the impact of usage on NCLEX-PN success. As discussed earlier, the nature of the NCLEX-PN data (pass/fail) and the high percentage of students passing the NCLEX-PN on their first try renders analysis complex as there is little or no variation in student outcomes. Future endeavors will focus on securing more detailed data from students and faculty about NCLEX question numbers, pass rates, and prior student course performance in their nursing programs. This information 8 Transforming Nursing Education and Nursing Practice Together can help better predict students at-risk for failing the NCLEX-PN and provide more insight into factors which may predict success. We will also continue to explore the extent to which prepU usage influences student learning, mastery of course material, and ultimately student success on the NCLEX-PN. Additional research is needed to help elucidate the best practices for NCLEX-PN preparation during school and after graduation, and to better understand how active studying (e.g., adaptive quizzing) impacts NCLEX-PN preparation and outcomes.

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success References Kaplowitz, M. D., Hadlock, T. D., & Levine, R. (2004). A comparison of web and mail survey response rates. The Public Opinion Quarterly, 68 , 94–101. Karpicke, J.D., & Blunt J.R. (2011). Retrieval practice produces more learning than elaborative studying with concept mapping. Science, 331: 772-775. National Federation of Licensed Practical Nurses, Inc. (NFLPN). (2003). Nursing practice standards for the licensed practical/vocational nurse. Raleigh, NC: Author. NCLEX Statistics (2012). https://www.ncsbn.org/Table of Pass Rates 2012.pdf NCLEX Statistics (2013). https://www.ncsbn.org/Table of Pass Rates 2013.pdf NCLEX-PN Test Plan. (2014). Chicago: National Council of State Boards of Nursing, Inc Phelan J. C. (2012). An investigation of student use of PrepU and NCLEX success. [White Paper, Philadephia, PA]. Phelan, J., & and Orm, J. (2012). Impact of Introductory Nursing Student Usage of an Online Adaptive Quizzing System: Case 2. Unpublished manuscript. Phelan, J., & Phelan, J.C. (2012). Impact of Introductory Non-Majors Biology Student Usage of an Online Adaptive Quizzing System. Unpublished manuscript. Phelan, J., & Phelan, J.C. (2011). Improving Biology Mastery Through Online Adaptive Quizzing: An Efficacy Study. In J. Herman (Chair), Toward Formative Assessments Supporting Learning: Design, Validation, and Mediating Factor. Poster presented at the annual meeting of the American Educational Research Association, New Orleans, LA. Phelan, J., & and Smith, B. (2012). Impact of Introductory Nursing Student Usage of an Online Adaptive Quizzing System. Unpublished manuscript. Roediger, H. L., & Butler, A. C. (2011). The critical role of retrieval practice in long-term retention. Trends in Cognitive Sciences, 15, 20–27. Sheehan, K.B. (2006). E-mail Survey Response Rates: A Review, Journal of Computer-Mediated Communication, 6 (2). 9 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Appendix A: Summary of Survey Questions (total sample) Question 2: How often did you use NCLEX 5,000 Powered by prepU (NCLEX 5,000) to prepare for the NCLEX? 10 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Question 3: If you used NCLEX 5,000, how well did you feel it helped to prepare you for the actual NCLEX? 11 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Question 4: Was NCLEX 5,000 the ONLY product you used to prepare for the NCLEX? 12 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Question 5: If NCLEX 5,000 was NOT the only product you used for NCLEX preparation, which of the following other materials did you use? 13 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Question 6: How did NCLEX 5,000 compare to other products you used for NCLEX preparation? Question 7: When did you/do you plan to take the NCLEX? Question 8: If you already took the NCLEX, did you pass on the first try? Question 9: If you took the NCLEX and passed on the first try, in how many questions did you do so (based on memory)? 157 students answered this question, but only 148 had valid responses. Some students wrote n/a or that they hadn’t yet taken the exam. 14 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Question 10: If you have not taken the NCLEX yet, may we contact you in the future to ask about the outcomes of your experience? Question 11: Additional comments: Please add any other comments about the NCLEX, NCLEX 5,000, competing products, or other issues that would be helpful in improving the student’s learning experience. 86 students included additional comments. The list of comments provided by students is shown below. They are sorted into “overall positive” comments and “critical comments”. These comments will be categorized and summarized (they are in Appendix B). At first glance, the main criticism for the NCLEX 5,000 is that students feel they are seeing repeated questions. This issue sometimes comes up because students will see the same question again, on a future quiz, if they did not answer correctly the first time. They may also see similar questions and think they are the same. 15 Transforming Nursing Education and Nursing Practice Together

An Investigation of Student Use of prepU NCLEX 5,000 and NCLEX-PN Success Appendix B: Detailed Student Feedback Positive Comments Critical Comments A Great Program. I’m glad my college recommended it. I was able to access the software anywhere to prepare. I did like that the areas you were weak in you could focus on those areas. Absolutely love it ! All was good and helpful An immediate rationale is not an option. Quizzes only come in 5, 10, and 20 question increments. The rationales are very nar rowly informed and some of the answers are incorrect, giving you false information. Only used this product because my school required it and for practice answering questions. Answer choices seem to be obviously easier than products such as ATI Can you give me an access to one month free? Excellent product. Felt it prepared me. Good practice answering questions similar to those found on the exam. thank you Great product! Would definitely recommend! Great tool to add to your learning experience! Great, I love how it explains WHY for everything and there is a large bank of questions! I did have problems accessing it at the beginning but the issue was resolved when I met one of the reps on campus. He helped me out and after that I had no issues. I did contact tech support prior to meeting him but the issue was not resolved until the rep helped me out. I have recommended prepU to other students. It was a great tool in preparing for the NCLEX. I felt as if it was a great way to get use to computer testing and the questions were very similar to those on the NCLEX I felt the NCLEX 5,000 was helpful no matter what because the questions and testing strategy is different than any others and it helps a lot. I had too many repetitive questions. 16

The NCLEX-PN test plan is organized into four client needs catego-ries, with a pre-determined percentage of items assigned to each cat-egory. The NCLEX-PN exam is a variable length CAT anywhere from 85 to 205 items long. The time limit for the exam is five hours (max-imum), and the length of the exam is determined by the candidate's

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