Critical Thinking to Ensure Clinical...

Running head: CRITICAL THINKING 1

Critical Thinking and Academic Success

in a Practical Nursing Program

Alicia Lundstrom

William Carey University

Joseph and Nancy Fail School of Nursing

Hattiesburg, MS

Submitted in Partial Fulfillment of NUR 646

Winter Term 2011

CRITICAL THINKING 2

Table of Contents

Page

Abstract…...……………………………………………………………………………... 4

Dedication……………………………………………………………………………….. 5

Acknowledgements……………………………………………………………………… 6

List of Tables…………………………………………………………………………….. 7

List of Illustrations………………………………………………………………………. 8

Section I. Introduction………………………..………………………………………… 9Background and Significance……………………………………………………. 9Purpose………………………………………………………………………..…. 11Project Questions……………………………………………………………….... 12Hypotheses…….……………………………………………………………….... 12Limitations……………………………………………………………………….. 13Theoretical Framework………………………………………………………….. 14

Definitions of Terms…………...………………………………………………... 16Summary………………………………………………………………………… 19

Section II. Review of Literature………………………………………………………… 21Introduction……………………………………………………………………... 21Theoretical Literature……………………………………………………………. 21Research Literature……………………………………………………………… 32Summary………………………………………………………………………… 38

Section III. Project Methods……………………………………………………………. 39Introduction……………………………………………………………………… 39Methodology…………………………………………………………………..... 39Setting………………………………………………………………………….... 41Sample...……………………………………………………………………….... 42Procedure...…………………………………………………………………….... 42

Data Collection………………………………………………..…………. 42Data Analysis………………………...………………………..……….... 43

Summary………...………………………………………………………………. 43

CRITICAL THINKING 3

Page

Section IV. Project Outcomes……………………………………………………………. 44Introduction…………………………………………………………………...….. 44Discussion……………………………………………………………………..…. 44Implications and Recommendations…...……………………………...…………. 50

Implications for Nursing Practice………………………………………… 50Implications for Nursing Education………………………………………. 50Implications for Nursing Research……………………………………….. 50

Summary………………………………………………………………………….. 51

References………………………………………………………………………………… 52

Appendices……………………………………………………………………………….. 56Appendix A. Consent, President of the College…………………………………. 56

Appendix B. Consent, Dean of Healthcare Education………………………….. 57Appendix C. Critical Thinking Data Collection Tool.…………………….……. 58

CRITICAL THINKING 4

Abstract

In an effort to lower attrition and improve academic success, as well as meet the increasing

demands of potential employers for competent nurses, it is essential for nurse educators to

consider factors that may serve as valid predictors of academic success in the program of studies

and licensure. The present study was a quantitative, descriptive, correlational, ex post facto

design. The purpose was to assess associations among score on the HESI®A2 CTE, exit GPA,

academic success (successful program completion), success meeting the benchmark HESI®Exit

Exam score, and success on the National Council Licensure Examination – Practical Nursing

(NCLEX®-PN) first write. A cohort of students (N=60) enrolled in a Practical Nursing program

in a small community college in central Mississippi comprised the convenience sample. Data

were collected via a retrospective records review. Results of the study suggest a statistically

significant association (p<0.05) between critical thinking score on the HESI®A2 CTE and

academic success in a Practical Nursing program, GPA, success in meeting benchmark

expectations established by the Practical Nursing program on the HESI®Exit Examination, and

success on the first write of the NCLEX®-PN. The critical thinking score on the HESI®A2 exam

is, therefore, recommended as a valid assessment criterion in the student admission process to

practical nursing programs.

Keywords: critical thinking, critical thinking skills, critical thinking assessment,

academic admission criteria, academic success, student retention, student attrition,

benchmarks, pre-licensure nursing student, HESI®, NCLEX®-PN ®

CRITICAL THINKING 5

Dedication

This project is lovingly dedicated to my family. To my grandfather, Lewis Purvis, whose

ambition in life was to see his grandchildren succeed, I miss you daily. I know you are smiling

down on me now. To my grandmother, Alice Ruth Purvis, thank you for all of the words of

encouragement and good times we share. To my parents, Lavon and Marcia Purvis, the values

you instilled in me and the encouragement you provided are the factors that have encouraged my

continued success. To my children, Cody and Caley, I pray that this project serves as

encouragement for you to fulfill your dreams the same way I have. Finally, to my husband, Jay

Lundstrom, you have always stood by my side and at times carried me on your shoulders. Thank

you for being as proud of this project as I am.

CRITICAL THINKING 6

Acknowledgements

I wish to express my sincere appreciation to the people who have assisted me in this

research process. To my major professor, Dr. Mari Wirfs, thank you for assisting me with

developing the study design and your editorial, data management, and statistical analysis

expertise. A special thank you is also extended to the faculty in the graduate program at William

Carey University. I would also like to thank Dr. Betsy Mann, Melanie Pinter, and Theresa Cole

for your unfailing support and encouragement throughout this process.

CRITICAL THINKING 7

CRITICAL THINKING 8

List of Tables

Page

Table 2.1. Distribution of Content for the NCLEX®-PN Test Plan…………..……… 25

Table 2.2. 2011 Number of Candidates Taking NCLEX®-PN Examination and Percent Passing by Type of Candidate…………….……………………...

27Table 2.3. Differences Between Groups for the TABE and Prerequisite Course

Grades…………………………………………………………………….. 30

Table 3.1. HESI®Exit Examination Scores and the Prediction of NCLEX®-PN

Success……………………………………………………………………. 41

Table 4.1. Descriptive Statistics: Age……………………………………………….. 45

Table 4.2. Descriptive Statistics: Gender and Race…………………………………. 45

Table 4.3. Descriptive Statistics: HESI®A2 CTE Scores……………………………. 46

Table 4.4. Intercorrelations: HESI®A2 CTE Scores, GPA, and HESI®

Benchmark Expectations……………………………………..………….. 47

Table 4.5. Frequency Distribution: HESI®A2 CTE Scores and Academic Success in the Practical Nursing Program………………………………………… 48

Table 4.6. Frequency Distribution: HESI®A2 CTE Scores and Academic Success on the NCLEX®-PN First-Write Attempt……………………………….. 49

CRITICAL THINKING 9

List of Illustrations

Page

Figure 1.1. Model of Developmental Stages of Critical Thinking……………………. 16

CRITICAL THINKING 10

Section I

When preparing potential nursing professionals to enter the healthcare industry, nurse

educators recognize the vital importance of graduating students who have the ability to think

critically and provide safe, competent care for healthcare consumers. Similarly, in an effort to

meet the competencies outlined by accrediting bodies, nurse educators must identify students

with the most potential for success in the nursing program of studies. Assessment of critical

thinking ability prior to admission and upon completion of the nursing program can assist nurse

educators in improving attrition and graduating competent and confident nursing students

(Banning, 2006).

Background and Significance

Critical thinking continues to resonate among nurse educators as a topic of discussion

when considering admission criteria as predictors of academic success. Accrediting agencies as

well as healthcare education institutions value student retention. Accordingly, nursing education

programs establish student admission and benchmark criteria in an effort to promote academic

success. However, the ability of nurse educators to assess the critical thinking ability of potential

nursing students is hindered for reasons such as:

1. insufficient knowledge regarding critical thinking;

2. insufficient knowledge regarding methods to incorporate critical thinking into the

nursing curriculum; and

3. insufficient knowledge regarding methods to assess students’ critical thinking

abilities (Vacek, 2009).

Banning (2006) points that the impact of critical thinking as it relates to nursing care may

be viewed from two major perspectives. First and primarily, quality client care is linked to the


ability of nurses to think critically in the planning, provision, and evaluation of care. Research

suggests a strong association between nursing professionals who enter practice in advanced

stages of critical thinking development and improved client outcomes in the acute care setting.

Similarly, persons who are proficient in practicing critical thinking demonstrate the necessary

trait of continuing to develop their own critical thinking skills as well as continuing to grow

professionally (Banning, 2006).

The second perspective emanates from Centers for Medicare and Medicaid Services

(CMS) which began in 2001 with the initiative of pay-for-performance to healthcare facilities.

This reimbursement initiative delineates particular health conditions that are ineligible for

reimbursement in specified healthcare settings. For example, catheter-associated urinary tract

infections and vascular catheter-associated infections are ineligible for reimbursement for

hospitals under the pay-for-performance initiative. As a result, healthcare facilities began to

push harder for improvements in quality of care provided to healthcare consumers. Staff nurses

play an active role in this quality and are held accountable for improvements in the immediate

care as well as progression of care for the client. Quality consumer care requires critical thinking

on the part of nurses charged with the provision of that care (Hines & Yu, 2009).

In an effort to promote critical thinking skills in potential nursing professionals, nurse

educators should work diligently to incorporate critical thinking instruction and practice into the

nursing curriculum. Because of the ongoing knowledge base expansion required of nurses,

development of critical thinking skills is essential to produce competent and confident program

graduates. Further, quantitative research regarding critical thinking skills of nursing program

applicants is important to achieve the goals of programs for student success.


Romeo (2010) suggests that critical thinking dispositions should be evaluated with

beginning and graduating nursing students. However, to measure a student’s critical thinking

disposition as a beginning nursing student and a graduating nursing student would require the use

of a non-nursing specific critical thinking disposition inventory because beginning nursing

students have very limited or no knowledge base related to nursing. While the use of this non-

nursing specific tool would quantify data for critical thinking dispositions, the certainty that it

would be an accurate indicator for nursing specific outcomes is debatable. Furthermore, the use

of two different critical thinking inventories would also produce inaccuracies in regard to

assessment of the critical thinking capabilities of potential nursing professionals (Romeo, 2010).

Nurse educators also struggle with developing strategies to implement critical thinking

activities into nursing curricula. In recent years, the implementation of clinical simulation

activities and problem-based learning activities has helped to introduce the concept of critical

thinking exercises into traditional nursing curricula (Kaddoura, 2010). In an effort to ensure that

their programs produce competent new graduates to meet the demands of the healthcare

workforce, nurse educators continue to search for strategies to develop critical thinking skills in

their students, as well as consider the validity of assessing pre-nursing student dispositions

toward critical thinking in the pre-admission screening and selection process.

Purpose

The purpose of this project is to examine associations among the following variables:

1. critical thinking capabilities of pre-admission nursing students;

2. successful program completion;

3. grade point average (GPA) in a Practical Nursing program;

4. ability to meet benchmark score established by the program on the Health Education


Systems Incorporated (HESI®) Exit Examination; and

5. success on the National Council Licensure Examination – Practical Nursing

(NCLEX®-PN) on the first write.

Conceptual and research literature was reviewed to ascertain current knowledge in the area of

interest. Results of an examination of critical thinking ability of applicants to a nursing program

and academic success would have implications for examination of the admission practices of

program.

Project Questions

1. Is the cumulative critical thinking score on the HESI®Admission Assessment (A2)

associated with academic success of students enrolled in a Practical Nursing

program?

2. Is the cumulative critical thinking score on the HESI®A2 associated with the exit

GPA of students enrolled in a Practical Nursing program?

3. Is the cumulative critical thinking score on the HESI®A2 associated with benchmark

HESI®Exit Examination score of students enrolled in a Practical Nursing program?

4. Is the cumulative critical thinking score on the HESI®A2 associated with success on

the NCLEX®-PN first-write of students enrolled in a Practical Nursing program?

Hypotheses

To answer the research questions, this investigator posed the following four hypotheses.

Each is stated in the research (H1) and in the null (H0) form. The level of statistical significance

for rejection of null hypotheses was p≤.05.


research hypothesis 1 (H1:1). Critical thinking score on the HESI®A2 is positively

associated with the academic success of students enrolled in a Practical Nursing program.

null hypothesis 1 (H0:1). There is no association between critical thinking score on the

HESI®A2 and the academic success of students enrolled in a Practical Nursing program.


associated with the exit GPA of students enrolled in a Practical Nursing program.

null hypothesis 2 (H0:2). Critical thinking score on the HESI®A2 is not associated with

the exit GPA of students enrolled in a Practical Nursing program.


associated with the benchmark HESI® Exit Examination score of students enrolled in a Practical

Nursing program.


the benchmark HESI® Exit Examination score of students enrolled in a Practical Nursing

program.


associated with success on the NCLEX®-PN first-write attempt of students enrolled in a Practical

Nursing program.


success on the NCLEX®-PN first-write attempt of students enrolled in a Practical Nursing

program.

Limitations

This investigator identified several study limitations. This study was limited to a small

cohort of students enrolled in only one practical nursing program and the program is located in a


rural geographical setting. Data were collected from student records which could result in

missing data for some cases. Academic failure is only one factor resulting in student attrition.

Confounding variables (such as personal reasons, financial issues, change in study focus) were

not addressed in the study. Critical thinking ability in the theoretical realm may not necessarily

transfer to the clinical practice arena. The present study did not account for student attrition due

to clinical performance issues.

Theoretical Framework

According to the Foundation for Critical Thinking (2011), critical thinking is defined as

“the intellectually disciplined process of actively and skillfully conceptualizing, applying,

analyzing, synthesizing, and/or evaluating information gathered from, or generated by,

observation, experience, reflection, reasoning, or communication, as a guide to belief and

action.” The theoretical framework for this study was Richard Paul and Linda Elder’s

developmental stage theory. These theorists identified six sequential stages of critical thinking

development. At stage one is the unreflective thinker. Unreflective thinkers lack the capacity to

identify problems within their own thinking skills. Stage two is the challenged thinker.

Challenged thinkers begin to recognize problems and/or inconsistencies with their thinking

skills. As these problems are recognized, the person enters stage three of development; the

beginning thinker.

Beginning thinkers recognize problems and attempt to correct problems, albeit

sporadically. Stage three tends to be the point of plateau for many individuals. Stage four is the

practicing thinker; one who continues to advance in the skills of thinking and reasoning. Stage

five is the advanced thinker. Advanced thinkers do not have to put forth as much effort to think

critically; however, they do continue to require some extrinsic motivation. At the sixth, most


advanced and fully developed, stage is the accomplished thinker. Accomplished thinkers are

those who think critically without any extrinsic motivation (Paul & Elder, 2009).

Theoretically, students who have entered stage four of critical thinking development

should perform well in both nursing education courses and on NCLEX®. However, continued

success in professions requiring mastery of critical thinking skills requires advancement above

stage four in critical thinking development (Paul & Elder, 2009). These individuals should have

the ability to identify questions and problems, gather and assess relevant information using

abstract ideas, interpret the relevant information, and perform actions based on the relevant

information and standards identified in the profession. Additionally, these individuals should

possess the capabilities of thinking open-mindedly using alternative thought processes,

recognizing and assessing assumptions, implications and consequences, and communicating

effectively with others in order to identify possible solutions to complex problems (The

Foundation for Critical Thinking website, 2011). The goal of the nursing educator is to foster the

critical thinking skills of nursing students so that they become a minimum of stage four thinkers.

A model of Paul and Elder’s (2008) developmental stages of critical thinking as it relates to

nursing education is depicted in Figure 1.1.


Figure 1.1 Model of Developmental Stages of Critical Thinking

Definition of Terms

academic success.

theoretical definition. According to Ablard (1996), academic success is defined

as the perception of the student in regards to internal and external factors they identify

with academic success.

Pre-Admission Nursing Student

Nursing Student

Preparing to Take Initial Licensure

Exam


operational definition. For the purpose of this study, academic success is defined

as successful completion of the Practical Nursing program East Central Community

College.

critical thinking ability/skill.

theoretical definition. According to The Foundation for Critical Thinking (2011),

the following skills are essential to an effective critical thinker:

1. raises vital questions and problems, formulating them clearly and concisely;

2. gathers and assesses relevant information, using abstract ideas to interpret it

effectively, comes to well-reasoned conclusions and solutions, testing them

against relevant criteria and standards;

3. thinks open-mindedly within alternative systems of thought, recognizing and

assessing, as need be, their assumptions, implications, and practical

consequences; and

4. communicates effectively with others in figuring out solutions to complex

problems.

operational definition. For the purpose of this study, critical thinking ability/skill

is defined as the score on the critical thinking component of the HESI®A2 (CTE) prior to

admission to the Practical Nursing program.

grade point average (GPA).

theoretical definition. As defined in Merriam-Webster’s Online Dictionary

(2011), GPA is the average obtained by adding the total number of grade points earned

and dividing it by the total number of credit hours attempted.


operational definition. For the purpose of this study, GPA is defined as the

resulting three digit value (on a four-point scale, rounded to the nearest hundredth)

obtained by summing the total number of grade points earned in the Practical Nursing

curriculum and dividing that number by the total number of credit hours attempted earned

in the Practical Nursing at East Central Community College.

HESI®exit examination benchmark score.

theoretical definition. According to the Evolve Learning System website (2011),

benchmark score indicating an average probability of student success on NCLEX®-PN is

greater than or equal to 850.

operational definition. For the purpose of this study, the HESI®Exit Examination

benchmark score for prediction of NCLEX®-PN success is a minimum score of 850.

NCLEX-PN®.

theoretical definition. The NCLEX®-PN is a computer-based assessment

administered to candidates who have completed a Practical Nursing program at an

accredited institution. The assessment is designed to measure competencies of the

candidates to perform safely as a newly-licensed nurse (National Council of State Boards

of Nursing website, 2012).

operational definition. For the purpose of this study, NCLEX®-PN is defined as a

computer-based assessment administered to candidates who have completed a Practical

Nursing program at an accredited institution, in an effort to measure competencies of the

candidates to perform safely as a newly-licensed nurse.


NCLEX®-PN First Write Attempt.

theoretical definition. According to the Mississippi Board of Nursing (2008), the

NCLEX®-PN first-write attempt is the initial attempt to pass the computer-based

NCLEX®-PN examination by the student who has successfully completed an accredited

Practical Nursing program in Mississippi.

operational definition. For the purpose of this study, NCLEX®-PN first-write

attempt is defined as the initial attempt to pass the computer-based NCLEX®-PN

examination by the student who has successfully completed the Practical Nursing

program at East Central Community College.

Summary

Nursing professionals must possess the ability to think critically to be able to provide

competent and confident care to healthcare consumers. Nurse educators have the very important

responsibility of guiding potential nursing professionals through the critical thinking processes

and applying the skills in the clinical practice setting. However, nurse educators face challenges

in accomplishing this task. These challenges include, but are not limited to:

1. lack of a nursing-specific definition of critical thinking;

2. difficulty evaluating critical thinking in nursing students;

3. lack of a nursing-specific tool to measure nursing students’ ability to think critically;

and

4. inability to evaluate critical thinking capabilities at the entry level and graduating

level with the same tool (Romeo, 2010).

In conclusion, it is the responsibility of nurse educators to incorporate critical thinking

into the nursing curriculum, to help students learn to apply critical thinking in the clinical arena


as well as develop methods to evaluate the critical thinking skills of nursing students prior to or

at the beginning, during, and on completion of their nursing education. Nurse educators not only

bear the responsibility of teaching students a knowledge base, but they also bear the

responsibility of ensuring that potential nursing professionals possess the ability to continue to

expand upon this knowledge base. For this reason, it is imperative that nurse educators embrace

critical thinking in their instructional skill repertoires. In so doing, the desired outcome of

graduating confident and competent nursing professionals who are successful on the NCLEX®-

PN may be achieved. This section presented the background and significance of the study, the

purpose, research questions, hypotheses, limitations, theoretical framework, and definitions of

terms for the present study. In the next section, Section II, this author presents an overview of

the conceptual and theoretical literature relevant to the study.


Section II

Review of Literature

Introduction

The following section examines current literature related to critical thinking in nursing

education. The literature review was conducted by hand, internet, and online library database

searches from literature published January, 2000 to May, 2011. The Cumulative Index for

Nursing and Allied Health Literature (CINAHL) was the primary resource for internet-based

searches. Search words utilized in various combinations included, but were not limited to:

critical thinking, critical thinking ability/skills, critical thinking assessment, academic admission

criteria, academic success, student retention, student attrition, benchmarks, pre-licensure nursing

student, HESI®, and NCLEX®-PN. Research related to critical thinking examination prior to

student acceptance into a nursing program is very limited. Quantitative research regarding the

role of critical thinking in continued academic success was also limited. However, numerous

studies were available that examined the role of critical thinking and NCLEX® success rates. A

review of the relevant theoretical and research literature follows.

Theoretical Literature

Critical thinking became a primary focus in nursing education in the 1990s. Critical

thinking in the nursing profession is essential in the provision of high quality nursing care. The

National League for Nursing (NLN) and the American Association of Colleges of Nursing

(AACN) cite critical thinking as a core competency for nursing education. Accrediting agencies

such as the National League for Nursing Accrediting Commission (NLNAC) and the

Commission on Collegiate Nursing Education (CCNE) all require nursing education programs to

include critical thinking components in program curriculums, as well as develop methods to


assess the ability of students to meet these required outcomes. By ensuring that students possess

the ability to think critically, the nursing education institution assists in training nurses who are

professionally accountable (Rubenfeld & Scheffer, 2006).

According to The Foundation for Critical Thinking (2011), critical thinking is defined as

that mode of thinking – about any subject, content, or problem – in which the thinker improves

the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking

and imposing intellectual standards upon them. The ongoing development of critical thinking

skills requires the thinker to continuously analyze thought processes in an effort to prevent

distorted thinking. Practicing thinkers are able to process information based on principles of

intelligibility, correctness, meticulousness, reliability, importance, substantiated evidence, good

reasons, profundity, extent, and fairness (The Foundation for Critical Thinking website, 2011).

Healthcare employers value critical thinking skills. Educational institutions must

graduate students capable of meeting the challenges of the emerging workforce. According to

Elder (2000), employees are challenged by the continued growth and complexity of job

requirements, technological advancements that replace jobs, and continued growth of required

employee involvement in efforts to ensure quality improvement. Large amounts of revenue are

lost due to inattention to the principles of intelligibility, correctness, meticulousness, reliability,

importance, substantiated evidence, good reasons, profundity, extent, and fairness. The educator

is challenged to foster the critical thinking skills of students in order to ensure the successful

transition from student to professional (Elder, 2000).

Critical thinking is an essential component in the provision of safe care for healthcare

consumers. Heaslip (2008) argues that critical thinking in nursing directly impacts clinical

decision-making skills and these skills are based on eight elements of thought:


1. the problem, question, concern, or issue;

2. the purpose or goal;

3. the frame of reference;

4. the assumptions held true;

5. the central concepts, ideas, principles, and theories used in reasoning;

6. the evidence, data, or information provided to substantiate the reasoning;

7. the interpretations, inferences, and reasoning that lead to the conclusion; and

8. the implications and consequences that follow from the solution.

Nurse educators focus on fostering the continued growth of these skills through classroom and

clinical experiences aimed at requiring the use of these elements (Heaslip, 2008).

Billings and Halstead (2009) examined the role of critical thinking in nursing education,

stating that nursing is a profession that is practiced in a complex environment on complex

beings. Furthermore, continuing technological advancements require that nurses be more

inclined to examine thought processes behind patient care, rather than just perform the

psychomotor skills associated with patient care. Therefore, it is the responsibility of nursing

education institutions to examine the ability of students to think critically prior to admission and

upon completion of a nursing program (Billings & Halstead, 2009).

The most effective way to determine the role of a critical thinking assessment tool in the

admission criteria of a particular nursing program is to examine the relative scores of a critical

thinking assessment tool measured with defined academic success of the institution. Billings and

Halstead (2009) discussed three different tools that can be utilized in the assessment of critical

thinking skills in students. However, the fallacy with each of these tools is the lack of nursing-

specific assessments that can be utilized to gauge the ability of students to think critically


(Billings & Halstead, 2009). The three tools discussed by Billings and Halstead are reviewed

below.

The first tool, the Watson-Glaser Critical Thinking Appraisal (WGCTA), consists of

different problems encountered in daily living. The WGCTA measures five different areas.

These areas include deduction, inference, recognition of assumptions, interpretation, and

evaluation of arguments. The test consists of multiple choice questions, with each different area

containing a total of 16 questions. Each different area is weighted evenly, and the maximum

score on the examination is 80. Billings and Halstead (2009) reported on a study performed by

Bauwens and Gerhard in 1987 in which the WGCTA was used to predict academic success on

NCLEX® examination scores. The study tested the critical thinking capacity of nursing students

prior to admission and upon completion of the nursing program. The results of the study found

that there were no significant changes in the result of critical thinking scores on this tool between

the times administered (Billings & Halstead, 2009).

The second critical thinking inventory is the California Critical Thinking Skills Test

(CCTST). This inventory is a standardized 34-question multiple choice test. The inventory

provides an overall score, as well as a score of subscales which include analysis, evaluation,

inference, deductive reasoning, and inductive reasoning. However, the literature related to the

use of the CCTST with nursing students is very limited (Billings & Halstead, 2009).

The third instrument discussed by Billings and Halstead (2009) is the California Critical

Thinking Disposition Inventory (CCTDI). This inventory is a 75-item inventory which utilizes a

six-point Likert scale to gauge the critical thinking dispositions of students in seven different

subscales. These subscales include open-mindedness, analyticity, maturity, truth-seeking,

systematicity, inquisitiveness, and self-confidence. The inventory reports an overall score, as


well as a score in each of the seven different subscales. Similar to the CCTST, the CCTDI has

not been utilized extensively in nursing education; therefore, available literature related to the

use of this tool is also limited (Billings & Halstead, 2009).

The NCLEX® is a computer-based assessment developed by the National Council for

State Boards of Nursing (NCSBN) utilized by state boards of nursing to assess the ability of

entry-level nurses to practice in a competent manner. The NCLEX® examination consists of two

versions– NCLEX®-RN and NCLEX®-PN. Requirements to take the NCLEX® examination are

not established by NCSBN, but rather by individual state boards of nursing (National Council of

State Boards of Nursing website, 2012). Qualified applicants who meet of exceed the

benchmark passing score may be issued a license to practice nursing in the state (providing there

are no other disqualifying factors).

The NCLEX®-PN utilizes the principles of Bloom’s Taxonomy to assess the ability of

students to perform at the application level or higher. The test plan is divided into four major

client needs categories, with two of these categories divided into subcategories. These categories

and their distribution of content on the exam are illustrated in Table 2.1.

Table 2.1: Distribution of Content for the NCLEX®-PN Test Plan

Client Needs Percentage of Items from Each Category/Subcategory

Safe and Effective Care Environment Coordinated Care Safety and Infection Control

13 – 19%11 – 17%

Health Promotion and Maintenance 7 – 13%Psychosocial Integrity 7 – 13% Physiological Integrity

Basic Care and Comfort Pharmacological Therapies Reduction of Risk Potential Physiological Adaptations

9 – 15%11– 17% 9 – 15% 9 – 15%

(2011 NCLEX®-PN Detailed Test Plan, 2011)


The student must be able to integrate concepts from the social sciences and biological sciences,

as well as demonstrate clinical problem-solving ability (nursing process), caring, communication

and documentation, and teaching and learning in addition to the four client needs categories

specified in the 2011 NCLEX®-PN detailed test plan (2011 NCLEX®-PN Detailed Test Plan,

2011).

The computer-based NCLEX®-PN consists of a databank of test questions ranging from

85 to 205 questions, of which 25 are pretest items that are not scored. A five-hour time limit is

allotted for completion of the exam and begins when the candidate sits down and begins the

tutorial (and includes scheduled/unscheduled breaks). The test consists of different item formats

including multiple choice, multiple response, fill-in-the-blank, hot spot, exhibit, drag and drop,

ordered response, audio, and graphic (2011 NCLEX®-PN Detailed Test Plan, 2011).

The number of items on the test for a given candidate is based on the computerized

adaptive testing (CAT) model which targets items to the candidate’s ability by reviewing

answers to previously answered questions. If the candidate responds to an item correctly, the

CAT model searches the database for an item that is approximately equal in difficulty to the

current question. If the candidate replies incorrectly, the CAT model re-estimates the

candidate’s ability and chooses another item based on the determination. This is an ongoing

process until it is determined with 95% probability that the candidate has the ability to practice

nursing safely in an entry-level position (2011 NCLEX®-PN Detailed Test Plan, 2011).

Two constraints are placed on NCLEX®-PN in order to assure validity of the exam to

determine the ability of the candidate to practice safely. For candidates requiring multiple

attempts on the NCLEX®-PN, the computer prevents the questions from previous attempts

(within the last year) from re-appearing on the candidate’s exam. The second constraint ensures


that the test plan specifications set forth by the four major client needs categories are met with

each attempt by the candidate (2011 NCLEX®-PN Detailed Test Plan, 2011).

NCSBN maintains records of NCLEX®-PN attempts. The data for 2011 is presented in

Table 2.2

Table 2.2: 2011 Number of Candidates Taking NCLEX®-PN Examination and Percent Passing, by Type of Candidate

PN Jan–Mar20113

Apr-Jun 20114

Jul-Sep 2011

Oct-Dec 2011

Year to Date 2011

Type of Candidate

# % # % # % # % # %

First Time, US Educated

16,521 87.58 13,121 82.08 22,291 87.00 13,401 80.53 65,334 84.83

Repeat, US Educated

3,255 42.70 3,429 27.47 3,502 35.29 3,789 34.57 13,975 34.91

First Time, Internationally Educated

211 51.66 214 36.45 159 49.06 171 46.20 755 45.56

Repeat, Internationally Educated

226 27.88 244 16.39 214 12.62 201 16.42 885 18.42

All Candidates 20,213 79.31 17,008 69.56 26,166 79.24 17,562 69.55 80,949 75.12

1 The # symbol denotes the number of candidates who took the exam.2 The % symbol denotes the percentage of candidates that passed the exam.3 The PN passing standard was -0.37 logits.4 Beginning April 1, 2011 the PN passing standard was changed from -0.37 to -0.27 logits.

(National Council of State Boards of Nursing website, 2012)

Nurse educators bear the responsibility of preparing students for NCLEX®-PN and must

face this challenge by exposing students to similar assessment measures utilized by NCLEX®-

PN. HESI® exams are an assessment tool used by many nursing education institutions to assist

with this process. HESI® offers numerous nursing-specific exams including but not limited to

admission assessments (with/without critical thinking), specialty examinations, and exit

examinations (Evolve Learning System website, 2011).


The HESI®A2 is a computer-based assessment exam consisting of 275 multiple-choice

items, with four choices per item. The test consists of five categories: science (Biology,

Chemistry, and Anatomy and Physiology), vocabulary and general knowledge, reading

comprehension, grammar, and basic math skills. The admission assessment may or may not be

administered with additional components including learning style, critical thinking, and

personality style (Evolve Learning System website, 2011).

The HESI®A2 CTE is a 30-item computer-based assessment of critical thinking ability.

This exam is a multiple-choice test, with four options for each test item. All answers are correct;

however, each choice reflects a different degree of critical thinking skill. Possible score ranges

from 0 to 1000, with a higher score indicating a higher level of ability to think critically within

the discipline of nursing. The recommended time to complete the exam is 30 minutes, and the

CTE score is not included in the comprehensive HESI®A2 score (Evolve Learning System

website, 2011).

Academic success directly impacts the student, employer, and economy. Research

conducted by the National Center for Education Statistics (2009) indicates that a higher level of

education in adults often leads to higher employment rates and higher salaries. Similarly,

academic success transcends to individuals who are more stable in employment, more likely to

have health insurance, be less dependent on public assistance programs, and be more involved in

their communities. Crime rates were also lower among individuals with a higher level of

education (National Center for Education Statistics website, 2009).

Nursing student attrition is a major cause for concern. In order to meet the demands of

the ongoing nursing shortage, retention of nursing students is a challenge facing nurse educators.

Stickney (2006) conducted a study of factors affecting Practical Nursing student attrition for 153


Practical Nursing students in a community college in central Florida. The sample was divided

into two groups: the group who completed the one-year program on schedule (retention group)

and the group who did not (attrition group). The researcher examined variables including scores

on the Test of Adult Basic Education (TABE) and grades in required prerequisite courses.

Demographic variables including age, gender, and race were also investigated (Stickney, 2008).

Attrition rates for the demographic variables age and gender did not reveal statistically

significant results; whereas, attrition rates for the demographic variable race were statistically

significant. A cross-tabulation analysis of data revealed a higher attrition rate for male students

(37.5%) than female students (36.6%). Students 36 to 45 years-of-age (n=13) had an attrition

rate of 48.1% (40% for ages 46 years and older (n=8) and between 33% and 40% for all other

age ranges). The attrition rate for Caucasian students (30%) was significantly lower than the

attrition rate for African American students (48%), Hispanic students (44.4%) and Asian students

(50%) (Stickney, 2008).

Stickney (2008) found that the variables TABE scores and grades in required prerequisite

courses were statistically different (p<.05) among minority and majority groups. Table 2.3

presents these findings. Stickney (2008) recommended implementation of a retention program

dealing with academic learning and study skills in pre-admission nursing students. According to

this researcher, early interventions in academic areas as identified by the TABE would assist in

improving attrition rates among Practical Nursing students.


Table 2.3: Differences Between Groups for the TABE and Prerequisite Course Grades

Measure M SD t pTABE math

White Minority

11.5110.08

2.072.33

3.98 0.000

TABE verbal White Minority

12.039.47

1.793.19

6.34 0.000

TABE reading White Minority

12.3410.93

1.232.48

4.65 0.000

Introduction to Health Care course White Minority

3.413.05

0.680.72

3.17 0.002

Medical Terminology course White Minority

3.282.85

0.770.81

3.30 0.001

(Stickney, 2008)

Student progression is important for the student, the nursing program, and the educational

institution. A study of 556 associate degree nursing students in central Texas was aimed at

identifying factors associated with student progression. Of the original sample (N=556), 385 of

the students successfully completed the program and completed the first-write attempt for the

NCLEX®-PN. The students were then divided into two groups. Group one (n=328) was

comprised of students who successfully completed the program and passed NCLEX®-PN on the

first-write. Group two (n=58) was comprised of students who successfully completed the

program and did not pass NCLEX®-PN on the first-write (Tipton et al., 2008).

The researchers examined variables associated with progression including academic

performance in nursing courses, scores on the Nurse Entrance Test (NET), the type of test taker,

and presence of stressors. Researchers conducted an independent samples t-test (equal variances

not assumed) of GPA in nursing courses which revealed that small differences in nursing course


grades could identify students who are at risk to be unsuccessful (Group 1, M=79.60; Group 2,

M=76.88) (Tipton et al., 2008).

The NET is a standardized exam that assesses information on the examinee’s reading and

math abilities, types of stressors, and test-taker profile. Researchers found that NET scores did

not significantly predict students’ ability to progress in nursing education by utilizing a smaller

randomized sample (N=68) to perform a t-test between the two groups (t (66)=.907, p=.368)

(Tipton et al., 2008).

The NET also categorizes test takers as frustrated, instructional, or independent.

Frustrated test takers have difficulty taking multiple choice and true/false tests. Instructional test

takers have difficulty determining the most appropriate option on multiple choice examinations.

Independent test takers are considered to have minimal difficulty with multiple-choice and

true/false examinations. A chi-square analysis suggested that the proportion of test-taking types

between the two groups was not statistically significant (?2(2)=.3296, p=.192) (Tipton et al.,

2008).

Stressors are commonly thought to play a significant role in student progression/attrition.

The NET identifies stressors including family, social, money/time, academics, and/or work.

Separate Goodness of Fit Chi-square analyses conducted between the two groups suggested no

significant differences with any of the stressors (all ? 2s >.05). However, the setting for the

study employed a licensed counselor who provided group stress management sessions and

individual counseling sessions for students included in the study on an as needed basis (Tipton et

al., 2008).


Research Literature

Quantitative studies of critical thinking as a predictor of success in pre-admission nursing

students are very limited. Some of the reasons are difficulty in evaluating levels of critical

thinking, the lack of nursing specific tools designed to measure critical thinking skills, and the

assumption by professionals that success on the NCLEX®-PN identifies competency in critical

thinking. While the majority of questions on the NCLEX®-PN are application and analysis level

on Bloom’s Taxonomy, it is incorrect to assume that a student possesses adequate critical

thinking capabilities to care for complex beings in complex environments based on these results

(Romeo, 2010).

Research conducted in the Netherlands demonstrated the effect of critical thinking

instruction in students required to make complex decisions and perform in complex

environments. The research was composed of two field studies in crisis management situations

for military personnel. In the first study, printed scenarios were presented to 16 officers of the

Royal Netherlands Air Force. Eight of the officers were provided an additional instruction sheet

explaining critical thinking. Results of the study indicated that the students who were provided

with the critical thinking instruction sheet obtained higher grades than the group who did not

receive the critical thinking instruction sheet; however, the results were not statistically

significant (Helsdingen, Van den Bosch, Van Gog, & Van Merrienboer, 2010).

The second field study was implemented in a high fidelity simulation setting.

Participants were divided into eight member teams, with one team receiving critical thinking

instruction throughout the simulation scenario. According to investigator reports, the team that

received the critical thinking instruction throughout the scenario scored significantly higher

(M=2.88, SD=0.37, p≤.05) on the decision-making process portion of the simulation scenario test


and the decision outcomes portion of the simulation scenario test (M=2.42, SD=0.36, p≤.05) than

the control group. The results of the control group on the decision making process portion of the

exam were M=2.20, SD=0.23 and the results on the decision outcomes portion of the exam were

M=1.69, SD=0.39 (Helsdingen et al., 2010).

Although this study was not nursing-specific, findings supported the hypothesis that

critical thinking and decision outcomes share a direct relationship. That is, the ability of a

student to think critically directly influences the decisions that are made and ultimately, the

effects of those decisions. This is a key concept in critical thinking instruction and evaluation for

nurse educators.

Nursing education institutions face challenges in trying to prepare students to enter the

complex world of the nursing profession, while ensuring that students enter the workforce with a

passion for providing compassionate nursing care that endures throughout their career in nursing.

A descriptive, correlational study performed by Zurmehly (2008) examined the relations of

educational preparation, autonomy, and critical thinking to nursing job satisfaction. The study

included a sample size of 140 registered nurses who practiced in medical-surgical,

administrative, and home health care settings. The study utilized the WGCTA and the

Minnesota Satisfaction Questionnaire (Zurmehly, 2008).

Data analysis revealed a statistically significant (r=.538, p<.05) relationship between

autonomy and job satisfaction and a statistically significant relationship (r=.442, p<.05) between

scores on the WGCTA and job satisfaction. Educational preparation and job satisfaction data

indicated bachelor’s prepared nurses were most satisfied (M=66.25), followed by master’s

prepared nurses (M=63.30), associate’s degree nurses (M=56.57), and diploma nurses

(M=44.26). A multiple regression analysis of the job satisfaction model utilizing all variables


demonstrated that the largest contributor to job satisfaction was critical thinking ability, followed

by self-perceived autonomy and then educational level (Zurmehly, 2008).

Wolkowitz and Kelley (2010) studied the academic predictors of success in a nursing

program. Their study examined the use of standardized tests including the Scholastic Aptitude

Test (SAT), the American College Test (ACT), the Nursing Entrance Test (NET), and the Test of

Essential Academic Skills (TEAS), for preadmission into a nursing program against Assessment

Technologies Institute’s (ATI) RN Fundamentals assessment for students in the first semester of

a nursing program. The SAT and the ACT are standardized tests used primarily to gain

acceptance to a post-secondary institution, while the NET, TEAS, and ATI RN Fundamentals

assessment are utilized primarily in nursing education. A total of 4,105 nursing students’ scores

on the TEAS and ATI RN Fundamentals assessment were evaluated. Data were gathered only

for first-time examination attempts (Wolkowitz & Kelley, 2010).

The TEAS provides an overall score and sub-scores for reading, mathematics, science,

and English and the ATI RN Fundamental assessment is an assessment tool utilized in nursing

education to gauge the success of students enrolled in courses fundamental to nursing education.

The investigators found that sub-scores of the TEAS showed a low correlation between the score

on the admission assessment and performance on the ATI RN Fundamentals assessment.

However, the amount of variance for the science sub-scores (r=0.15) indicated that this score is

accurate 14.9% of the time in predicting success on the ATI RN Fundamental Assessment

(Wolkowitz & Kelley, 2010).

Romeo (2010) surveyed the research literature on the measurement of critical thinking

capabilities and usefulness of critical thinking as a prediction of NCLEX® performance. This

investigator discovered a large volume of research on critical thinking in nursing education and


found similar problems in each. Lack of a nursing-specific tool and nursing definition of critical

thinking were cited as common core problems. Also, Romeo (2010) cited student attrition as a

primary problem in researchers’ attempts to obtain quantitative data in the pre-admission stages

and graduate stages of nursing education. Furthermore, any research done to quantify critical

thinking as a predictor of academic success on the NCLEX® must utilize comparison analysis

between students who are successful and those who are not successful (Romeo, 2010).

An expected outcome of nursing education is the ability of graduates to be able to

perform timely while caring for clients in a complex and continuously changing environment. In

order to meet these expectations, newly graduated nurses must be able to think critically. In a

study conducted in the Netherlands, researchers attempted to describe critical thinking

dispositions among newly graduated nurses. They examined student background variables as

predictors of critical thinking disposition (Wangensteen, Johansson, Bjorkstrom, & Nordstrom,

2010).

This cross-sectional, descriptive study sample was drawn from a population of 1,900

newly graduated nursing students in 18 different colleges in Norway. Of the 656 volunteers

responding to an invitation to participate, 42 did not meet inclusion criteria and were excluded

from the study. A total of 614 (N=1,900, n=614 [32.3%]) nurses comprised the convenience

sample and completed a study-specific questionnaire and the CCTDI. In analyzing the data, the

researchers found that 90% of the newly graduated nurses scored above the recommended score

of 40 on the CCTDI inquisitiveness subscale of the tool, indicating a strong disposition toward

continued learning (Wangensteen et al., 2010).

Associations between the background variables, age and university education prior to

nursing education were statistically significant. Persons 30 years-of-age and older had higher


CCTDI scores than persons younger than 30 (88% vs. 75%). Additionally, people with

university education prior to entry into nursing education had higher scores on the CCTDI (87%

vs. 79%). Results of this study indicated that older age and post-secondary preparation prior to

admission into nursing education are associated with greater critical thinking ability

(Wangensteen et al., 2010).

Rogers (2010) conducted a qualitative study at a school of nursing that admitted

approximately 96 new students annually. The school had a retention rate of 80% and the

NCLEX®-PN first time pass rate was approximately 89%. Faculty and students were interviewed

with a series of questions aimed at identifying factors that the individuals felt secured success in

the nursing program and emerging trends were identified. The emerging trends were categorized

into three different subgroups: student related, collaborative, and curriculum related. Critical

thinking skills emerged as a recurring theme among both faculty and students (Rogers, 2010).

In a study of 54 fourth semester nursing students enrolled in a 17-week NCLEX®-PN

review course, Lyons (2008) utilized the ATI Critical Thinking Test to measure the critical

thinking skills of students prior to, and upon completion, of the course. Participants were

divided into two groups: a problem-based learning group and a lecture group. The problem-

based learning group was assigned tasks to help foster critical thinking skills and the lecture

group received traditional classroom lecture. Lyons (2008) reported that 88.9% of the

participants passed the NCLEX®-PN on the first-write within six months of completion of the

review course. First-time pass rates between the problem-based learning group and the lecture

group were statistically significant, with 93% (n=27) of participants in the problem-based

learning group passing the NCLEX®-PN on the first-write and only 85% (n=27) of the lecture

group passing on the first-write (Lyons, 2008).


Although not a statistically significant finding, results of the ATI Critical Thinking

Examination revealed higher scores for the lecture group (M=65.5, p=NS) than for the problem-

based learning group (M=64.4, p=NS). The post-course mean score for the students who

participated in the lecture group was 68.9 and the post-course mean score for the problem-based

learning group was 67.9. Lyons (2008) concluded that the students receiving additional

instruction in critical thinking achieved better results from the review course than the students

who received traditional lecture.

Higgins (2005) investigated relationships between program completion and NCLEX®-PN

pass rates, prerequisite courses, preadmission test components, demographic variables, HESI®

Exit Examination scores, and nursing skills laboratory scores. The study sample was composed

of 213 records of previously enrolled associate degree nursing students of a program in Texas.

Higgins (2005) reported that a significant difference between successful completion of the

program and prerequisite course grades in Anatomy and Physiology II (r =.152, p<.05) and

Microbiology (R2=.191, p<.05). Results of comparisons with English and mathematics courses

were not statistically significant. Additionally, the study results revealed that scores on the

preadmission assessment demonstrated a statistically significant correlation with completion of

the nursing program: reading (r=0.124, p<.05), science (r= 0.184, p<.05), and math (r= 0.129,

p<.05). The data further iterates the notion that critical thinking ability is a major factor in the

future academic success of potential nursing students (Higgins, 2005).

Summary


Nurse educators face challenges in the attainment of student success, from program

admission to program completion to licensure. Student attrition is a major problem for students

and nurse educators alike. In an attempt to reduce attrition rates, educators review and adjust

admission criteria based on simple program-level statistics, accrediting agency requirements, and

current research literature. But as multiple variables may potentially influence academic success,

identification and quantification of variables associated with academic success is a complex task

requiring valid measures.

Section II presented a review of theoretical and research literature. The role of critical

thinking in the changing face of the nursing profession is a call to action for nurse educators to

continue researching the value and utility of assessing critical thinking in pre-licensure nursing

students, as an indicator, or predictor, of academic success. In order to accomplish this task, this

researcher believes it wise for nurse educators to examine program admission criteria and

evaluate pre-licensure students’ critical thinking abilities prior to entering the nursing program

and again upon completion of the program. The research reviewed herein does suggest a

positive correlation between the ability to think critically and successful progression in nursing

education. Additionally, critical thinking capacity of nursing students is a significant indicator of

the ability of potential nursing professionals to think autonomously and deliver safe, quality

nursing care. Section III is a discussion of project methods in the present study, including the

setting, sample, and data collection and analysis procedures.

Section III


Project Methods

Introduction

As indicated in the review of literature, the ability to think critically has been identified

by employers and the profession as a desired trait among newly graduated nurses. Furthermore,

the evaluation of the student’s ability to critically think must be a factor in the nursing program

admission process (Zurmehly, 2008). To accomplish this requires that nurse educators have

reliable methods to quantify the ability of pre-licensure and graduate nursing students to think

critically. Section III presents the methodology for testing the hypotheses and answering the

research questions and in the present study. The study is designed (setting, sample, data

collection, and data analysis) to examine relationships among the HESI®A2 Critical Thinking

Exam (CTE) score, academic success, GPA, ability to meet benchmark scores established by the

Practical Nursing program on the HESI® Exit Examination, and success on NCLEX®-PN first

write attempt in a cohort of Practical Nursing students.

Methodology

This study was quantitative, correlational, ex post facto, descriptive research. Data were

obtained via a retrospective review of student records from Fall, 2009 through Fall, 2010.

Variables in the review were scores on the HESI®A2 CTE, academic success rates in the

Practical Nursing program, exit GPA, benchmark scores established by the Practical Nursing

program on the HESI®Exit Examination, and academic success on NCLEX®-PN first write

attempt.

The HESI®A2 CTE is a 30-item computer-based assessment of critical thinking ability.

This exam is a multiple-choice test, with four options for each test item. All answers are correct;

however, each choice reflects a different degree of critical thinking skill. Possible score ranges


from 0 to 1000, with a higher score indicating a higher level of ability to think critically within

the discipline of nursing. The recommended time to complete the exam is 30 minutes, and the

CTE score is not included in the comprehensive HESI®A2 score (Evolve Learning System

website, 2011). After data was collected, nursing faculty was educated regarding the correlation

between critical thinking capabilities and the above mentioned factors in an effort to encourage

nursing faculty to evaluate current admission criteria for the Practical Nursing program in order

to foster improved academic success rates.

GPA was defined as the resulting three digit value (on a four-point scale, rounded to the

nearest hundredth) obtained by summing the total number of grade points earned in the Practical

Nursing curriculum and dividing that number by the total number of credit hours attempted

earned in the Practical Nursing at East Central Community College. This value represents the

GPA of the Practical Nursing program only, as no prerequisite courses are required for

admission to the program.

The HESI® Exit Examination is a 150-item computer-based assessment designed to

identify strengths and weaknesses of Practical Nursing students nearing program completion.

The examination is scored using the HESI® Predictability Model (HPM) which is a mathematical

formula that considers the difficulty of each item in order to determine the student’s performance

on the exam. Scores range from 0 to 1000. Two versions of the examination are available and

remediation is recommended based upon the results (Evolve Learning System website, 2011).

HESI® utilizes research findings to establish recommended benchmark scores on the exit

examination, in an effort to predict NCLEX®-PN success. Table 3.1 lists the results of the

findings.

Table 3.1: HESI® Exit Examination Scores and the Prediction of NCLEX®-PN Success


HESI® Scoring Interval Description

A. 950 < OUTSTANDING probability of passing

B. 900 – 949 EXCELLENT probability of passing

C. 850 – 899 AVERAGE probability of passing

D. 800 – 849 Below average probability of passing

E. 750 – 799 Additional preparation needed

F. 700 – 749 Serious preparation needed

G. 650 – 699 Grave danger of failing

H. < 649 Poor performance expected

(Evolve Learning System website, 2011)

The benchmark score established by the Practical Nursing program is 850 and is based on

recommendations by HESI for student to have average probability of passing NCLEX®-PN first-

write.

Setting

The setting for this study was a Practical Nursing program in a school of nursing in a

small, rural community college in Central Mississippi. Student records are stored in the

healthcare education building. The school admits approximately 30 students to the program

annually. The HESI®A2 CTE is currently administered to students seeking enrollment in the

program; however, the scores are not evaluated for admission to the program.

Sample


A total of 60 Practical Nursing student records were audited from the classes of students

admitted in Fall, 2009 and Fall, 2010. Inclusion criteria for study participation included a score

on the HESI®A2 CTE and admission to the Practical Nursing program. Students who did not

meet the above inclusion criteria were excluded. Institutional and student data were coded using

numbers or pseudonyms and all files were retained in a confidential and secure place.

The ages of students ranged from 19 years to 54 years (M=30.37). There were six (10%)

males and 54 (90%) females. The majority of students resided primarily in the five-county rural

district served by the community college: Leake, Neshoba, Newton, Scott, and Winston counties.

There were 35 (58.33%) Caucasian students and 25 (41.67%) African-American students

included in the study. There were no other races represented in the sample.

Procedure

data collection.

Prior to proceeding with data collection, written consent was requested and received from

the President of the college (Appendix A) and the dean of the school of nursing (Appendix B).

The researcher was available to answer questions regarding the research prior to consent being

obtained. All parties were provided with two contact telephone numbers for further information

regarding the study, including that of the researcher and the dean of the School of Nursing at

William Carey University.

In order to facilitate data collection and recording, an investigator-developed data

collection tool was utilized (Appendix C). Student record audits were conducted by this

researcher of the class of students admitted in Fall, 2009 and the Fall, 2010. Demographic data

included the student age, race and gender. Admission scores on the critical thinking portion of

the HESI®A2 exam, scores on the first HESI® Exit Examination, student grades and successful


program completion were obtained in the records audit and successful completion of NCLEX®-

PN on the first write was obtained from the office of the Dean.

data analysis.

Data were analyzed using Winks SDA software. Descriptive statistics were obtained for

variables age, gender, race, HESI®A2 CTE score, GPA, HESI®Exit Exam score, and NCLEX®-PN

first-write. The Pearson Product Moment Correlation Coefficient (Pearson r) was applied to the data to

test correlations among HESI®A2 CTE score, GPA, and HESI® Exit Examination scores. The level of

statistical probability for rejection of null hypotheses (H01, H02, H03, H04) and acceptance of research

hypotheses (H11, H12, H13, H14) was p<.05.

Summary

The purpose of the present study was to examine relationships among the HESI®A2

Critical Thinking Exam (CTE) score, academic success, GPA, benchmark scores established by

the Practical Nursing program on the HESI® Exit Examination, and success on NCLEX®-PN

first- write attempt in a cohort of Practical Nursing students. Section III presented the

methodology for testing the hypothesis and answering the research questions. Section IV

presents a discussion of findings and implications for nursing practice, nursing education, and

nursing research.

Section IV


Project Outcomes

Introduction

Nurse educators are challenged to assess the potential for success of potential nursing

students. For this reason, it is imperative that nurse educators take an active role in gathering

and interpreting data thought to be potential predictors of academic success. Critical thinking

ability has been identified by researchers as a significant factor in the prediction of academic

success. Therefore, nurse educators are wise to assess the critical thinking capabilities of

potential nursing students toward the goal of improving student outcomes. These important

outcomes include academic success in the program of studies and success on the NCLEX®-PN

first write. The purpose of the present study was to examine relationships among the HESI®A2

Critical Thinking Exam (CTE) score, academic success, GPA, ability to meet benchmark scores

established by the Practical Nursing program on the HESI®Exit Examination, and success on

NCLEX®-PN first- write attempt in a cohort of Practical Nursing students. Section IV is a

discussion of the study outcomes with implications and recommendations posited by this

investigator.

Discussion

Descriptive statistics were applied to the data to examine frequencies and central

tendencies of the variables. Descriptive analysis of data includes the mean of the group of

numbers, standard deviation from the mean, the minimum observed number, and the maximum

observed number. Frequency distributions allow the researcher to see the most frequently

occurring scores, as well as identify any patterns in the distribution of scores (LoBiondo-Wood

& Haber, 2010). Descriptive statistics were utilized to describe the demographic data: age,


gender, and race. Descriptive statistics were also utilized to analyze the HESI®A2 CTE scores of

students admitted into the Practical Nursing program.

A total of 60 student records were audited and the data pertaining to the variables of

interest were entered into the data analysis procedures. The demographic variable age with

descriptive statistics is presented in Table 4.1. The variables gender and race with descriptive

statistics are presented in Table 4.2. Student scores on the HESI®A2 CTE with descriptive

statistics are presented in Table 4.3.

Table 4.1: DESCRIPTIVE STATISTICS: AGE

N=60

FIELD N MEAN STD SEM MIN MAX ----- - ---- --- --- --- ---

AGE 60 30.37 9.96 1.29 19 54

As depicted in table 4.1, the mean age of students admitted into the Practical Nursing

program was 30.37 with a standard deviation of 9.96 years. The sample group ranged in age

from 19 to 54 years.

Table 4.2: DESCRIPTIVE STATISTICS: GENDER AND RACE

N=60

Frequency Table 4.2.1: GENDER

Cumulative Cumulative GENDER Frequency Percent Frequency Percent ----------------------------------------------------------- Male 6 10.0 6 10.0 Female 54 90.0 60 100.0

Frequency Table 4.2.2: RACE

Cumulative Cumulative RACE Frequency Percent Frequency Percent ----------------------------------------------------------- Caucasian 35 58.33 35 58.33 African-American 25 41.67 60 100.0


As depicted in table 4.2, six (10%) male students and 54 (90%) female students were

admitted into the Practical Nursing program for the inclusion time period. Of the 60 students, 35

(58.33%) students were Caucasian and 25 (41.67%) students were African-American. There

were no other races represented in the sample group.

Table 4.3: DESCRIPTIVE STATISTICS: HESI®A2 CTE SCORES

N=60

FIELD N MEAN STD SEM MIN MAX ----- - ---- --- --- --- ---

CT SCORE 60 792.67 64.88 8.38 550 900 As depicted in table 4.3, the mean score on the HESI®A2 CTE for the sample group was 792.67

with a standard deviation of 64.88. The scores ranged from 550 to 900.

According to Burns and Grove (2009), a descriptive correlational design investigates

relationships existing in a situation. The design focuses specifically on relationships among study

variables. Data pertaining to the ability of the student score on the HESI®A2 CTE to predict

GPA, the ability of the student to meet the established benchmark of the Practical Nursing

program on the HESI® Exit Examination, the evaluation of successful completion of the Practical

Nursing program, and success on the NCLEX®-PN examination on the first write was analyzed

utilizing the Pearson product moment correlation coefficient (Pearson r, [r]). Student scores on

the HESI®A2 CTE were entered as the independent variable in the Pearson equation. GPA and

score on the HESI® Exit Examination were entered into the Pearson equation as the dependent

variables. GPA of students who successfully completed the Practical Nursing program ranged

from 2.50 [250] to 3.49 [349] (M=3.10 [310], SD=22.87). HESI® Exit Examination scores

ranged from 670 to 1134 (M=845, SD=99.10).


Table 4.4: INTERCORRELATION: HESI®A2 CTE SCORES, GPA, AND HESI®EXIT EXAM BENCHMARK EXPECTATIONS

GPA HESI® EXIT EXAM HESI®A2 CTE SCORES .309 .291 (.016*) (.024*) [ 60] [ 60]

* p<.05

Results of the Pearson correlation analysis as depicted in table 4.4 indicate a positive

correlation (r =.309, p =.016) between scores on the HESI®A2 CTE and GPA. Similarly, the data

also indicate a statistically significant (p<.05) positive correlation (r =.291, p=.024) between

scores on the HESI®A2 CTE and meeting benchmark requirements established by the Practical

Nursing program on the HESI® Exit Examination. That is, greater ability to think critically, as

measured by the HESI®A2 CTE prior to admission to the Practical Nursing program, is

significantly associated with greater academic success (as measured by GPA) in the nursing

program of studies.

Frequency distribution tables were generated to identify associations between HESI®A2

CTE Scores and academic success in the Practical Nursing program (table 4.5) and associations

between HESI®A2 CTE scores and academic success on the NCLEX®-PN first-write attempt

(Table 4.6).


Table 4.5: FREQUENCY DISTRIBUTION: HESI®A2 CTE SCORES AND ACADEMIC SUCCESS IN THE PRACTICAL NURSING PROGRAM

N=60

Frequency Table 4.5.1: Students Successful in the Practical Nursing Program

Cumulative Cumulative HESI®A2 CTE SCORE Frequency Percent Frequency Percent ------------------------------------------------------------- 740 1 2.94 1 2.94 750 1 2.94 2 5.88 760 4 11.76 6 17.65 770 1 2.94 7 20.59 780 5 14.71 12 35.29 790 3 8.82 15 44.12 800 3 8.82 18 52.94 810 2 5.88 20 58.82 820 2 5.88 22 64.71 830 1 2.94 23 67.65 840 5 14.71 28 82.35 860 1 2.94 29 85.29 870 1 2.94 30 88.24 880 2 5.88 32 94.12 890 1 2.94 33 97.06 900 1 2.94 34 100.0

Frequency Table 4.5.2: Students Unsuccessful in the Practical Nursing Program

Cumulative Cumulative HESI®A2 CTE SCORE Frequency Percent Frequency Percent ---------------------------------------------------------------- 550 1 3.85 1 3.85 600 1 3.85 2 7.69 680 2 7.69 4 15.38 710 1 3.85 5 19.23 720 1 3.85 6 23.08 740 1 3.85 7 26.92 750 1 3.85 8 30.77 760 2 7.69 10 38.46 770 3 11.54 13 50.0 780 2 7.69 15 57.69 790 2 7.69 17 65.38 800 1 3.85 18 69.23 820 2 7.69 20 76.92 830 1 3.85 21 80.77 840 1 3.85 22 84.62 860 1 3.85 23 88.46 880 2 7.69 25 96.15 890 1 3.85 26 100.0


Table 4.5 indicates that students scoring below 740 on the HESI®A2 CTE were

unsuccessful in the nursing program (p<.05). The frequency table does not categorize data of

students who scored above 740 on the HESI®A2 CTE who were unsuccessful. Other factors

contributing to non-success in the program include personal reasons, financial issues, change in

study focus, and other non-related items are not accounted for in the frequency table.

Table 4.6 FREQUENCY DISTRIBUTION: HESI®A2 CTE SCORES AND STUDENT SUCCESS ON NCLEX®-PN FIRST-WRITE ATTEMPTN=60

Frequency Table 4.6.1: Students Successful on NCLEX®-PN First Write Attempt

Cumulative Cumulative HESI®A2 CTE SCORE Frequency Percent Frequency Percent -------------------------------------------------------------------- 750 1 3.45 1 3.45 760 2 6.9 3 10.34 770 1 3.45 4 13.79 780 5 17.24 9 31.03 790 2 6.9 11 37.93 800 3 10.34 14 48.28 810 2 6.9 16 55.17 820 2 6.9 18 62.07 830 1 3.45 19 65.52 840 5 17.24 24 82.76 860 1 3.45 25 86.21 870 1 3.45 26 89.66 880 1 3.45 27 93.1 890 1 3.45 28 96.55 900 1 3.45 29 100.0

Frequency Table 4.6.2: Students Unsuccessful on NCLEX®-PN First-Write Attempt

Cumulative Cumulative HESI®A2 CTE SCORE Frequency Percent Frequency Percent ------------------------------------------------------------------- 740 1 50.0 1 50.0 880 1 50.0 2 100.0

Ninety-four percent of students who scored above 740 on the HESI®A2 CTE were

successful on the first-write of the NCLEX®-PN (Table 4.6.A). According to the results of the

data analysis as depicted in tables 4.5 through 4.6, nurse educators may consider critical thinking


score on the HESI®A2 examination as a predictor of academic and NCLEX®-PN success among

potential nursing students.

Implications and Recommendations

implications for nursing practice.

The ability to think critically is essential to the success of newly graduated nursing

students. However, a portion of the task of continuing to foster the ability of students to achieve

life-long learning lies with employers. In an effort to secure positive patient outcomes, the

present research suggests that employers offer critical thinking activities in the form of

continuing education in to foster the continued development of critical thinking (as depicted in

the Model of Developmental Stages of Critical Thinking, figure 1.1).

implications for nursing education.

Outcomes of the present study suggest that a score of 740 or above on the HESI®A2 CTE

is positively associated with academic success, GPA, ability of the student to meet benchmark

expectations established by the Practical Nursing program, and success on NCLEX®-PN first

write attempts. Therefore, it is the recommendation of this investigator that nurse educators in

Practical Nursing programs consider the score obtained on the HESI®A2 CTE in admission

requirements in an effort to lower attrition and foster improved student outcomes during the

academic program of studies and NCLEX®-PN success on the first-write.

implications for nursing research.

This investigator recommends replication of the present study in larger cohorts of

Practical Nursing students. Further research regarding the use of the HESI®A2 CTE score, as

well as comparisons with other measurements of critical thinking prior to admission and upon

completion of a nursing program are recommended to further assess the significance of critical


thinking ability in the success of student outcomes. This author also recommends replication of

this study in populations of associate degree and baccalaureate degree nursing programs and

programs in urban as well as rural geographical locations. Lastly, this investigator recommends

research is warranted related to the ability of nursing students to advance above stage four on the

Model of Developmental Stages of Critical Thinking (figure 1.1) after graduation, entering the

nursing profession, and at various points in time as they gain experience in the practice arena.

Additional research may hopefully yield more data to quantify the impact of critical thinking

skills in both nursing education and the nursing profession.

Summary

Nurturing and encouraging the ability of nursing students to think critically has become a

primary task of the nurse educator. Encouraging students to think critically helps students

become independent thinkers who are capable of making timely, complex decisions in complex

environments. The present study has demonstrated that critical thinking ability is a factor that is

significantly associated with success in a Practical Nursing program in central Mississippi. This

finding supports prior research that the requirements of nurses to make complex decisions in

continuously changing and complex environments makes critical thinking skills a primary task

for nursing students to master.

Nurse educators face the challenge of evaluating critical thinking ability prior to students’

admission and on nursing program completion. Additionally, nurse educators also face the

challenge of fostering nursing students’ desires to become lifelong learners in order to apply

critical thinking skills in their professional practice as healthcare providers. By encouraging the

continuing development of students’ critical thinking skills, nurse educators contribute to the

ongoing development of competent and confident nursing professionals.


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Appendix A


Appendix B


Appendix C

Critical Thinking Data Collection Tool

Age of Student: Gender of Student: Race of Student:

◌ Male ◌ Caucasian

_________ ◌ Female ◌ AfricanAmerican

◌ Hispanic◌ Native

American◌ Other

Critical Thinking Score: PN Program GPA:

__________ _________

Student Score on HESI®Exit #1: Student Successful on NCLEX®-PN 1st Write:

__________ ◌ Yes

◌ No

Program Completion:

◌ Successful

◌ Unsuccessful

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