Qualitative Phenomenological Investigation Of The Perceptions Of Nursing Graduates

Table of Contents

Introduction 4
Problem Statement 11
Purpose and Significance 12
Research Questions 12
Limitations and Delimitations 13
Limitations 13
Delimitation 13
Researcher Assumptions 14
Definition of Terms 15
Wonderlic GAIN 15
Wonderlic SLE 15
HESI exit exam 16
Admission Criteria 16
Summary 16
Introduction 17
Review of Literature 17
Nursing Curricula in the United States 17
The Development of Nurses in Missouri 22
Admissions Criteria 22
Predicting Success in NCLEX-PN Programs 23
NCLEX-RN Predictors of Success 28
Wonderlic Scholastic Level Exam and Personnel Test 34
Completion of Nursing Program 36
Nursing Intervention in Practice 39
Ambiguous Nursing Terminology Constraints 39
Insufficient Support of Collegial Infrastructure 40
Need of Nurses for Older Adults 41
Constraining Force of Economics 42
Situation of Nurses in Workforce 42
Funding and Legislation of Programs 43
Involvement of Nursing in Healthy People 2020 45
Effective Strategies for NCLEX Success 45
Conceptual Framework 49
Summary 50
Introduction 52
Research Design 52
Research Setting/Context 53
Research Sample and Data Sources 56
Instruments and Procedures 57
Data Collection 59
Data Analysis 60
Confidentiality of the Data 60
Role of the Researcher 61
Methodological Limitation 62
Ethical Concerns 62
Summary 63

The nation is experiencing a critical shortage of healthcare providers, a shortage that is expected to increase in the next five years, just as the largest population in our nation's history reaches the age when increased medical care is necessary (Pike, 2002). Staffing of hospitals, clinics, and nursing homes is more critical than ever as the large numbers of 'baby-boomers' begin to realize the need for more frequent medical intervention and long term care. Interest in becoming a nurse has waned in recent years, probably due to the history of the intense and demanding educational process, low salary, inflexible and long hours, and rapid 'burn-out' of those practicing in the profession (Wharrad, 2003). A complex managed care environment in this nation is limiting the dollars available to be spent on nursing care. Many health professions, especially nursing, have the reputation of 'eating their young' rather than offering effective mentoring to grow future healthcare providers. As a result of these factors, the number of nurses has decreased and employers find themselves understaffed and competing for competent personnel. Prior to 2001 the decline had been evident for several years (Sadler, 2003).
Nursing schools, public leaders, healthcare leaders and the general public is affected by the lack of Registered Nurses (RNs) available. As the population ages, the expectation is that an increasing number of RNs will be required simply to maintain the current level of healthcare. In addition, the current environmental and political concerns of increasing pandemic disease, occurrence of manmade and natural disasters, and increasing threats of war, requires significant increases in the health care workforce (Jefferys, 2001). The national nursing shortage and factors that increase the demand for increasing the nursing workforce in the face of national, state, and local disasters create the potential for a public health crisis. Nursing programs have attempted to meet demand for nurses by increasing enrollment and lobbying successfully for increases in program funding by colleges and states for students. Unfortunately, the problem of nursing student attrition hampers the best efforts of nursing programs and aggravates the national shortage of Registered Nurses in the United States (Ofori, 2002).
In 2003, the National League for Nursing reported a positive upward trend in the nursing workforce supply however, the American College of Healthcare Executives (2006) reported that in 2005, 85% of hospital administrators determined hospitals did not have enough registered nurses to meet patient care demands. The United States Bureau of Labor statistics indicated by 2014, more than 1.2 million new and replacement nursing positions would be needed to meet the public healthcare needs (Ramsburg, 2007). Multiple extensive efforts to decrease attrition have been made by nursing programs including strengthening admission procedures and implementing retention programs. Regrettably, the problems of attrition continue to persist in nursing schools across the country. Admission to a nursing program is competitive and many potential students are denied admission each semester. Attrition from nursing programs affects not only the specific student who is accepted to a nursing program and unsuccessful, but also the student denied admission that may have been successful. Attrition rates are costly to students, nursing programs, and healthcare alike by decreasing the number of potential graduates from schools of nursing and contributing to the nursing shortage. Many studies highlight the much higher than desired attrition rates for nursing students and attempt to determine potential academic and non academic contributing causes of this undesired attrition rate (Ostrye, 2001).
According to Barr (1999), there is a paucity of data available on what factors influence student success; however, academic predictor variables fail to fully explain all of the factors that affect student performance. Many university's admission departments dedicate substantial time and money for the recruitment and admission of nursing students. Furthermore, admission staffs are tasked with the ever more difficult charge of distinguishing applicants who can be successful. Recruiting qualified applicants is just the beginning step in fostering program completion. After students are admitted, they ought to be afforded resources that will foster their persistence in the nursing program as well as promote their academic success. Retention as well as attrition of nursing students has been associated with demographic, academic, financial, cognitive, and personality/behavioral factors. Historically, many researchers have focused on intelligence quotient (IQ) when examining what promotes academic success. However, more recently scholars have begun to contemplate non-cognitive or psychosocial factors such as emotional intelligence, psychological empowerment, resilience, and spiritual well-being as a way to further academic success (Chow, 2001).
Particularly, researchers found that managing emotions was positively correlated with academic success. Other scholars have focused on how classroom techniques can promote psychological empowerment thus promoting academic success. Although, no research studies have examined the relationship between empowerment and academic success, there are some other researchers who have examined the relationship between academic success and resilience has been which demonstrated a positive correlation between the variables. Finally, scholars have linked spiritual well-being to many areas of functioning and support the relationship between spiritual well-being and academic success. Despite these studies and opinions, there is a paucity of research regarding the relationship of emotional intelligence, psychological empowerment, resilience, spiritual security of nursing students. Given the potential value of such factors in advancing academic success and therefore influencing outcomes such as retention, attrition, and graduation rates, research is warranted as it may provide insight into non-cognitive strategies that could be of potential advantage to this population (Lamm, 2000) .
The nursing shortage has waxed and waned for generations. Numerous health care experts and organizations have reported on the existing and projected nursing shortage. However, predictions related to the projected shortage of RNs in the United States have varied. The difficulty in determining the exact extent of the RN shortage is demonstrated by variations in the predicted 2020 RN shortage. Reported predictions on the RN shortage have stated numbers ranging from as low as 400,000, to as high as 800,000. However, despite variation in predicted numbers, it remains largely undisputed that a national shortage in the number of RNs exists, and some key indicators cannot be ignored (Penprase, 2013). The present nursing shortage is thought to have begun in 1998 and peaked in 2001. National Sample Survey of Registered Nurses (NSSRN) findings indicated the average age of licensed nurses has increased to 47 years from a previous 46.8 years in 2004, and the largest numbers of nurses in the workforce are in the 50-plus age group. The survey also reported that nurses are less likely to work in nursing as they age, and 76,915 nurses 55 years and older intend to leave the nursing profession within the next 3 years. This situation is further complicated by the large population of aging Baby Boomers likely living more life as compared to previous generations, and will be in need of more frequent and complex nursing care.
The availability of numerous alternative career opportunities for women who might have previously chosen nursing has also affected the supply of nurses. Finally, nursing burn-out is driving nurses either away from direct patient care or causing them to abandon the nursing profession altogether. These factors together with frequent and rapid changes in healthcare delivery make working in healthcare challenging and impact the supply of nurses. A number of approaches were attempted in an effort to ameliorate the nursing shortage. Strategies were designed to make nursing appear more desirable as a profession (Waters, 2006). In 2002, Johnson & Johnson marketed some commercials and short film descriptors featuring how nurses were instrumental in the care of patients. This campaign was centered on improving the image of nursing and encouraging individuals to choose nursing as a profession. The Johnson & Johnson campaign in conjunction with other media attention promoting nursing, and the national spotlight on the nursing shortage, garnered positive results in promoting nursing as a desirable career choice. Subsequently, a number of studies supported a positive shift in the image of nursing (Lockie, 2000).
A 2009 study by Buerhaus et al. found that increasing numbers of younger students were entering the nursing profession as a result of campaigns promoting nursing as a career. A 2006 study by Seago et al. involving 3,253 community college and university students in the Central Valley of California reported a general improvement in the image of nursing. The Seago et al. (2006) study also reported that many individuals were willing to choose nursing as a profession because of its high income potential and perceived job security. The perception was supported by a HRSA study that reported the average RN salary slightly outpaced inflation. Other studies have determined that even during periods of high unemployment, RN employment increased or remained stable. As the number of individuals choosing nursing as a career increased, applications to nursing programs also increased. This resulted in efforts to address the nursing shortage by increasing the number of students enrolling in RN programs. Other efforts to increase the number of RNs in the workforce have included the forging of contract education relationships between hospitals and nursing programs.
Contract education afforded hospital employees admissions into nursing programs upon completion of nursing program pre-requisite requirements. Other measures to increase the supply of working RNs involved economic incentives such as sign-on bonuses and increased hourly wages. These incentives were used to entice RNs to return to the workforce, to move from part-time work to full time, or to work non-mandatory overtime. Hospitals also recruited and hired foreign-born RNs to fill vacant RN positions. At any given time the extent of the nursing shortage is difficult to quantify. In 2007, it appeared the crisis level of the nursing shortage had somewhat abated (Ali, 2008). A PwC (2007) analysis attributed the perceived end of the nursing shortage to a significant number of late 20 and early 30-year old students entering the nursing profession in 2006. Despite the increase in the number of younger nurses entering the profession, Buerhaus et al. (2003) stated that a minimum increase of 40% more nurses would be necessary to fill the void left by retiring older nurses.

The 2010- 2011 Occupation Outlook Handbook predicted that employment opportunities for RNs were expected to grow at a significant rate because of the need to replace experienced nurses leaving the profession. Further, Buerhaus et al. (2003) identified a number of negative factors facing new RNs entering the profession that might impact their willingness to continue in the workforce. The most significant negative factor leading to new RNs leaving the nursing profession was job disillusionment. This disillusionment also resulted in job turn-over within 2 years by new RNs. A 2006 study by Seago et al. found that although the nursing profession was viewed more positively than previously, it was still regarded as a highly stressed injury-prone job with low professional autonomy. These findings may contribute to the continued inadequate supply of RNs. Some recent trends appear to indicate the nursing shortage may be ending. Still, experts caution against this conclusion. A study by Buerhaus et al. (2003) noted a decrease in the number of nursing job vacancies at hospitals, together with a concurrent rise in the number of new graduates unable to find jobs in these facilities. However, the study concluded that overall nursing employment and earning trends did not support an end to the nursing shortage. The 2009 Buerhaus et al., study attributed the recent decrease in the number of nursing job vacancies to many RNs delaying retirement, less job turnover, the return of retired or part-time nurses to the workforce, and increasing of work hours because spouses had either lost jobs, or feared losing their jobs. These RNs preferentially chose to work in hospitals where job security and wages were higher, fringe benefits were more favorable, and 12-hour shifts offered greater flexibility to work a second job (Buerhaus et al., 2009). This theory is supported by the 2008 NSSRN report indicating a first increase in full-time RN employment since 1996 from 58.4% in 2004 to 63.2% in 2008. The survey also reported that many RNs have more than one nursing job. As a result, a misleading impression has developed regarding an end to the nursing shortage. Other factors contributing to the false impression of an end to the nursing shortage may be the rising numbers of RNs requesting changes to their RN license status from inactive to active (Ramsburg, 2007).
High school grade point averages can be evaluated and used for admission screening, and some studies have shown them to be the best predictor of academic success in college (Salvatori, 2001). However, more non-traditional students than ever are returning to college many years after their high school graduation. These students bring years of real-world experience and developed work ethics which are not reflected in their high school grades but which could affect their college and health care profession success. Deficiencies in academic preparation often cause problems for nursing students when they enter nursing courses, resulting in major changes and/or failures. Defining academic success in college grade point averages and determining which prerequisite courses have the ability to predict success are important in a selective admission process (Lewis & Lewis 2000). Science and nursing course grades have been demonstrated as strong cognitive predictors of successful program completion (Campbell & Dickson, 1996), but students have already been accepted into a program at that point. Lewis and Lewis (2000) found successful students typically had taken two or more anatomy and physiology courses prior to nursing program admission. This study will aim to determine the predictors of student success in nursing programs that will assist nursing program selection committees in determining admission criteria that most accurately measures the potential for successful completion.

Problem Statement
The population of nurses in America is aging also, including the faculty responsible for the education of future nurses, hence colleges and universities are experiencing difficulties in finding competent, credentialed faculty. As the nursing shortage is published in the news media and talked about among the general population, an increasing number of individuals are seeking to enter the field as recent high school graduates or as adults returning to school for a second career. Enrollment in nursing programs increased steadily from 2001 ' 2006 according to the American Association of Colleges of Nursing (AACN). However, admission into most schools remains limited due to the faculty-student ratios required by state boards and national governing organizations, and due to the many unfilled faculty positions across the nation (Ramsburg, 2007). Data collected in 2006 by AACN shows that more that 32,000 program applicants who were academically qualified may have been turned away from nursing programs. In addition, many students who are accepted into nursing programs do not complete the program due to personal problems or failing grades. Because of the increasing health care needs, the shortage of professionals, and the economic climate, the burden falls on nursing programs to maintain a careful balance between accepted students and successful graduates. Nursing programs are now challenged by admissions decisions that will yield the highest retention and graduation rates. Pass rates on the national licensure exam, NCLEX, are also important in determining the success of students best suited for the nursing profession. Retention rates and graduation rates in Missouri are lower than the national benchmark because student selection committees cannot accurately identify predictor factors that adequately measure the probability of success in various entry-level nursing programs (Penprase, 2013).

Purpose and Significance
The purpose of the present descriptive-correlational study is identifying predictor factors that will help selection committees of nursing programs to determine criteria of admissions which most accurately measure the potential for successful completion within the prescribed curricular timeframe.
Screening and selective admissions processes for nursing programs are necessary to select the most qualified, most likely to succeed students in order to make the best use of the limited faculty members and admission slots. Graduates must be caring, competent, and capable of providing quality health care; and, they must be educationally prepared to pass national competency certification and licensure exams. Careful attention must be paid to the selection of the criteria that will be used in screening applicants. Although many approaches and combinations of criteria have been used in the past, it is more crucial than ever to screen applicants with tools that best predict the graduation of students, as well as their success on certification and licensure exams. Therefore, this research will be useful for assisting nursing program selection committees in determining admission criteria that most accurately measures the potential for successful completion.

Research Questions
' Is there a viable and measureable set of predictor factors that can predict the success of students in nursing programs?
' Is there a measureable correlation between admission criteria of a nursing programs and graduation rates?
' Is there one admission criteria that measures program success more effectively than any other?
' According to the student is the nursing program overall GPA, A&P, HESI exit exam, or cognitive ability the most accurate independent predictor of NCLEX success?

Limitations and Delimitations
The study will attempt to remove as much bias as possible and to minimize bias that objectivity is maintained. A limitation will be the availability of the target research group, nurses who have been working in different nursing homes and hospitals of Missouri. The target group will be nurses who have successfully completed their nursing programs and have been able cope-up with difficulties which occurred during this program. As the participants of the research will be selected from the available population therefore, research examples of definitions will be provided to the nurses for their convenience. It is assumed that all survey participants will truthfully attest that they are a part of the target segment as defined and fall within the range desired in terms of their successful completion of nursing program for the research study. However, some e-mail addresses may be unreliable, and some recipients of the e-mail invitation will be unwilling to participate. The proposed study is limited by the available financial resources to conduct the research; therefore, the results will be generalized only to those responding to the research survey.

Nurses to be surveyed are accessible due to the researcher's extensive network of contacts in Missouri. The participants have email accounts, which will provide access for participation in the questionnaire. Another delimiting factor is the availability of the targeted research group to participate in an online survey. Research in the academic world is being moved from paper and pencil to online surveys. Inviting population segments to visit a website for the purposes of completing a questionnaire is much more accessible and convenient for participants, thereby giving the researcher greater access to participants and a higher degree of participation success. Given that the population to be surveyed for this research has been the focus of many studies, the data collected will provide new insights to determine the predictors of student success in nursing programs.

Researcher Assumptions
Different scholars have defined 'Assumptions' as factors having the potential to influence overall outcomes of the research study and they cannot be documented by citing prior studies, provided that there is no past data is present. In addtion, assumptions of any research may also includes descriptive data, accuracy of instrument which is used by the reseacher to measure responses of the population and the honesty of the participants that whether they are participating on their own will or not. In the present research, the most initial assumption is that research particopants are honest during the interview. Since nurses selected for interviews have been connected with different issues in nursing programs therefore, it is important that they respond sincerely to the researcher. The honesty of the participatns has been assumed due to the fact that this research is dependent on the correct feedbacks from the nurses being interviewed. It will be by the researcher assumed that the nurses selected from Missouri can be generalized to nurses all over the USA. This assumption is relative to the diverse nature of nurses working all over the USA. The researcher will make sure that names of the survey will be anonymous by using numerical identification number on the interview notes in order to create such environment where privacy of participants is protected and this will create sense of openess and trust of these nurses. Finally, it has been assumed in this research that data which has been extracted from the past literature related to predictors of student success in nursing programs is reliable as well as authentic.
Definition of Terms
NCLEX-PN stands for National Council Licensure Examination-Practical Nurse and all the state and territorial boards of nursing in the US needs passing result on the exam for licensure as a licensed vocational nurse (LVN) or a licensed practical nurse (LPN).

National Council Licensure Examination-Registered Nurse (NCLEX-RN) is a exam which all the state and territorial nurses must have to pass in the US in order to become a registered nurse (RN). Overall, there are five processes of nursing which is used in NCLEX-RN and every questions falls into one of these five steps which are planning, analysis, assessment, intervention, and evaluation.

Wonderlic GAIN
The Wonderlic General Assessment of Instructional Needs (GAIN) is a reliable literacy and numeracy test of basic skills which is able to measure reading English and math capability of youth as well as adults. This test has been approved by the U.S. Department of Education and the U.S. Department of Labor for WIA Youth Workforce programs.

Wonderlic SLE
The Wonderlic Scholastic Level Exam (SLE) is a test of general cognitive capability towards understanding and learning instructions and information in order to resolve problems. To administrator, report and score online test of SLE is integrated and automated with the applicant management platform of Wonderlic Online and it can be managed in group settings or individual.

HESI exit exam
Health Education Systems Inc. (HESI) is a test, which is designed as a standardized test for nursing schools. Exit Exam of HESI is a standardized test which the students of nursing need to pass before graduating. The HESI exit exam is a complete nurse exam which is able to test general knowledge of students in key areas of the nursing curriculum. This exit test can be considered same as the NCLEX-RN and this is the reason performance on the HESI Exit Exam is a good predictor of nurse's willingness towards licensing exam.

Admission Criteria
The admission criterion is known as the requirements to enter in a specific course like skills, knowledge, experience and educational qualifications. In case of entering in nursing programs, admission criteria is dependent on educational qualification, experience and knowledge.

In the preceding chapter, problem statement, purpose and significance, research questions, limitations and delimitations and researcher assumptions were summarized. Chapter 1 also contained an outline of the unique definition of terms to be used in the study, and assumptions and limitations were identified. In Chapter 2 is a summary of the review of the literature that was conducted prior to the proposed study will be undertaken to explore any studies of the phenomenon under question.


This chapter is a comprehensive approach to examine literature related to the complexities of producing sufficient registered nurse graduates to meet health care needs. The first section of the chapter is a presentation of the title searches for the study and an explanation of the methods and terms utilized in conducting the extensive literature searches. The second section of this chapter covers a conceptual framework for the study.

Review of Literature
Nursing Curricula in the United States
Research on nursing curricula in the United states had determined that the nation's nursing shortage was severe that current registered nurses could not be considered a reliable workforce resource in the future, and that nursing curricular content needed to be addressed to meet health care requirements by Year 2020. Available data suggested that only 25% to 50% of the nurses who graduated from nursing schools would continue in their careers after five years in the profession. Despite the predicted shortage of about 800,000 nurses, or 29%, by 2020, a Health Affairs report in 2007 predicted the shortage of nurses to be 340,000 by 2020. The revised report still indicated that the projected nursing shortage would be three times larger than the size of the shortage when it was at its peak in 2001. Faculty shortages combined with an insufficient supply of new nurses with the credentials to teach in academic settings have led to predictions of greater shortages. Private sector recruitment from the already limited pool of qualified faculty members further complicated the problem. The need to identify elements that would attract and retain qualified nurses as faculty was urgent. Attractive elements could include educational program improvement, faculty training, higher salaries, loan repayment programs, or other incentives. Historically, nursing schools had been very structured in nature, but the content in health care education continued to expand, requiring significant analysis and modifications in curricula (Pike, 2002).
A study by Lasater and Nielsen, supported that the traditional clinical education model of total patient care was becoming no longer adequate. It had become incumbent upon nursing educators to not only facilitate the development of student skills and abilities to develop detailed care plans, but to create nursing leaders who believed that people matter, and to develop sensitivity to the needs of others. The leaders would need to be able to work with teams to extract from daily pressures encouragement for change, have the willingness to make a difference, and become critical and successful components in the implementation of change. According to a survey, opinion leaders viewed nurses as one of the most trusted of health information sources, but noted that they lacked a unified voice and showed an inability to focus on key health policy issues. Nurses however, have significant influence on key elements in a quality healthcare system and on improving patient care. This presented a challenge to nursing faculty to educate students to become acquainted with or proficient in policy and technology trends affecting health care. Nursing faculty had been resistant to using tools such as handheld computers or personal digital assistants to document clinical experiences, obtain information, or retrieve evidence supporting nursing practice (Lasater, & Nielsen, 2009, p. 441).
The resistance persisted despite increasing emphasis on evidenced-based practice. With the governmental directive that all hospitals in the United States transition to electronic medical records by 2014, nursing schools needed to include informatics into their curricula. Divergently thinking models have influenced people who were more inclined to be innovative, but there had been little incentive to become innovative when the familiar routines served adequately. The traditional roles in education were teaching, research, and service. There are three emerging Rs which are reward, recognition, and risk. Teaching and learning have become a combination of informatics, simulation, and e-learning, thereby creating powerful new learning environments. People are interdependent on personal and environmental influences, and their interactions are a bidirectional flow. It became essential that nurses develop an awareness and respect for the variety of religions, cultures, and lifetime occupations that are present among their patients (Boudreaux, 2006).
Changes in the lives of individuals may be perceived as disturbances of a crisis magnitude and previous maladaptive responses could compound into current ineffective coping. The maladaptive responses however, should not be attributed to psychopathology. Ineffective coping may result from a lack of information, behavior emanating from others in the environment, or the occurrence of a number of changes in a short time (Childs, 2004). There was a continuation of focus on the traditional acute care model of nursing, which was becoming more obsolete. There was an exponential increase in the amount and specificity of necessary curricular content since 2007, and the additional volume of content threatened to compromise opportunities for the exercise and refinement of critical thinking skills (Landry, 2010).
Curricula became saturated with content creating the need for a change in teaching methods from teacher-centered programming with conventional pedagogies that focused on gaining content and skill knowledge, toward student-centered learning with an adoption of alternative approaches to development of performance competency. There was an educational shift away from exclusively content and toward the individual experiencing the disease or problem. Even with the availability of appropriate tools, the shift away from teacher-directed, lecture-hall-style learning was difficult for many faculty members to embrace. Competency in critical thinking skills became essential as nurses were met by patients with a wide variety of concerns such as smoking cessation, stress management, diet and nutrition, exercise and fitness, disease management and prevention, mental health and self-esteem, conflict resolution, parenting, dealing with divorce, and elder care (Hopkins, 2006).
Learning by electronic media infiltrated all areas of education. Students need additional power over their course pace, content, sequence, learning time, and often the media format. Medical schools as well as nursing schools were challenged by the shortage of trained care professionals; curricula that were overcrowded; the transference of teaching venues to community settings and the transition to competency-based education models. The use and influence of e-learning continued to grow and demonstrate levels of effectiveness and efficiency in enhancing the knowledge and proficiency of new health care graduates (Ramsburg, 2007).
Creating e-learning materials could be expensive and it was not known whether the form of education was economically justifiable compared with the more traditional instructional methods. Multigenerational differences appeared in classrooms and workplaces and challenged nursing instructors. Student populations comprised Generation Y born after 1980, Generation X born between 1960 and 1980, to baby boomers born between 1943 and 1960. Some students entered nursing school without prior experience in the job market and some entered as a result of job loss or the desire for a career change. Some students held degrees in other fields. Older students represented diversity not only in age and gender, but brought with them life experiences and viewpoints that created challenges for nursing instructors. The educational needs of the students interrelated with financial and personal concerns and they valued their time and investment (Wharrad, 2003).
There were differences in values and work ethics between age groups which affected satisfactions with nursing careers. Occasionally the association between nurses became volatile and created tension, friction, and dissatisfaction. Young new graduates risked feeling intimidated by older more seasoned nurses whom they would have sought out as mentors, and they found that they were caring for a higher population of baby boomer patients. Managed care fostered a role expansion of the nurse and the managed care environment affected the milieu in which the nurses practiced. There was a shift from acute care to expanded community services, which affected the way health care was provided within hospitals. Medical and nursing curricula only presented end-of-life issues on a limited basis, but required all the skills in the nursing process of assessment, planning, implementation, and evaluation of appropriate interventions. A nurse who worked eight-hour shifts or longer, spend more time with her patients as compared to the physicians and it was essential that the nurses should be well informed about end-of-life issues (Ostrye, 2001).
Although there was a paradigm shift occurring in nursing education with an impetus to provide cost-effective quality education to an increasingly diverse student population, nursing curricula continued desperately in need of a major overhaul. Innovation in the programs focused on the rearrangement of content within curricula rather than on changes specifically reflecting paradigm shifts from knowledge bases to competency bases. It became essential that competencies in curricula target society's changing demographics and increasing diversity, the technological and scientific knowledge explosion, the national nursing shortage, and the urgency to provide a foundation for graduate education. There were professional, legal, and ethical implications of the expectations (Trossman, 2008).
Nursing has been one of the most regulated educational programs in colleges and universities, and responsive to a number of state-specific and national-level approval and accreditation constituencies. There were those who made the assumption that nursing, being non-linear in its evolution of knowledge development and paradigms, was not a legitimate science; that there was a lack of truth or ends of nursing science. Nursing sought scientific status as a means of social empowerment, and its research discourse articulated conceptual frameworks, research goals, logic behind studies, and sensitivities of research designs (Sayles, 2003).

The Development of Nurses in Missouri
Nursing development and research in Missouri has been important as the older adult population percentage continued to increase in Missouri proportionate to the rest of the state population. The nursing schools in Missouri began to address health needs and concerns of older adults from an innovative and collaborative perspective which included the university computer engineering and health informatics programs (Beeman, 2001). The Aging in Place project was envisioned by the school of nursing faculty in 1996. It developed to comprise Senior Care, a nursing practice focused on wellness; and TigerPlace, a residential environment of creative design where pets were welcomed and that involved the school of veterinary medicine. Among the topics discussed were holistic approaches, diabetes, infections, and transitions across care settings, drug therapy, fall prevention, chronic mental illness, and cognitive impairment. Continuing education units were awarded to nurses, nursing home administrators, and social workers who attended the conference (Lockie, 2000).
Admissions Criteria

Admissions criteria used for entry into nursing programs vary among programs. In an examination of community colleges admissions criteria, scholars have discovered a wide range of required pre-requisite admissions courses, units, and other criteria among programs (Ali, 2008). The literature revealed the inclusion of a variety of academic admissions criteria, including GPA, SAT, ACT, NLN, Preadmissions Test, Nurse Entrance Test (NET), and the Written Proficiency Examination (WPE), TEAS. Recent concerns regarding grade inflation, and the predictive value of GPA, has resulted in the more frequent inclusion of standardized tests as part of the admissions criteria in identifying students who are likely to succeed on the NCLEX-RN (Penprase, 2013). Variations in the admissions criteria used by nursing programs to admit students make outcomes assessment difficult. Moreover, a large proportion of studies related to admissions criteria and student success has been focused on baccalaureate programs. Therefore, few studies have addressed program completion and NCLEX-RN licensure success at the community college level, with even fewer studies related to the success of LVN students in community college associate's degree registered nursing programs (Landry, 2010).

Predicting Success in NCLEX-PN Programs
It is essential to review the practical nursing studies and the features that can predict success on the NCLEX-PN. The National League of Nursing (1954) undertook a study of 87 practical nursing schools in 1951. The study was to determine the extent to which the National League of Nursing Education (NLNE) selection tests for students and certain other personal characteristics were related to performance in the nursing program as well as to qualify for a license to practice. The results showed a positive relationship between scores earned on the NLNE preadmission and classification examination and scores on the practical nurse assessment scores and results earned on the licensing exam. The higher preadmission and classification scores were, the more likely it was that the student would complete the course (Sayles, 2003).
Meadow (1964) investigated a variety of selection techniques and their effectiveness in predicting academic success and on the job success of a selected group of 214 students in a school of practical nursing. An attempt was made to determine whether there were verifiable characteristics that distinguished the successful nursing candidate from the one who failed, and whether these characteristics can be identified in advance. The major finding in this research project was that a combination of predictor variables were found that could predict fairly accurately theory grade, achievement tests, and State Board Exam scores. The most important predictor was the composite score of the NLN pre-admission and classification test.
Seither (1974) investigated the predictive validity of selected admission screening measures involving 117 practical nursing students. Specifically, the California Short-Form Test of Mental Maturity, the California Reading Test, the California Test of Personality, and the age of the entrant were explored in this study. The results found that there is a positive association of age towards becoming successful in practical nursing as measured in NLN achievement scores, licensure exam scores, and student's clinical performance. Reading comprehension predicted most of the remaining variance.
Leitsch (1988) attempted to identify factors that predict success in practical nursing programs and to identify academically deficient students. Level of educational attainment as measured by end of (GED) program, high school or college courses were not found to be a useful predictor of success in LPN programs. The ability of gender to predict success was limited. Although the study found age to be correlated with passage or failure of the LPN Exit Competency Test, overall age was not a good predictor of success in LPN programs. Race also was not a predictor of success. Tests of Adult Basic Education (TABE) reading scores accounted for the largest percentage of variance in each of the criterion variables in both single and multiple regression analysis. The R was 0.0740 for the variance in passage or failure of the LPN Assessment Test (AT) accounted for by TABE reading scores. TABE mathematics scores accounted for only a small percent of the variance (7T = 0.0151).
Swift's (1989) study of 1,254 practical nursing students in 12 postsecondary schools in Georgia demonstrated no significant difference between rates of program completion for either high school graduates or GED recipients. However, GED recipients had significantly higher cumulative grade point averages as compared to high school graduates. Whereas age exhibited no significant relationship to the performance in terms of GPA and NCLEX results, race was found to be a factor in that African American students tended to have lower passage rates in comparison to the performance of Caucasian students on the NCLEX-PN.
Success is predominantly defined in the practical nursing research literature as passing on the NCLEX-PN examination. Thompson (1989) found SAT verbal, race, and age to be predictors of success for the practical nursing licensure examination. Some of these findings were contradictory to results reported in later studies. The sample consisted of 248 practical nursing students across the state of Georgia who graduated in 1987 and wrote the licensing examination. Independent variables included Test of Adult Basic Education scores; three sub-test scores of the Career Planning Program Test including reading, numerical skills, language skills, SAT, ACT, high school grade point average, age, and race. Sub-scores of each admission test were used as predictor variables in stepwise multiple regression analyses and analysis of variance was used to analyze the effect of age on licensure success or failure. The mean age for the subjects who failed the nursing examination was 24.55, while the mean age for the subjects who passed the examination was 27.82. Caucasians were more likely to have passing scores as compared to minorities, and the researcher also found a significant, positive relationship between SAT verbal scores and nursing licensure scores as well as between Career Program Reading Test scores and nursing licensure scores. Chi-square analysis found suburban programs to have significantly better passage rates as compared to the passage rates of programs located in urban or rural areas. Selected variables that might affect attrition in practical nursing programs and success on the NCLEX-PN in Alabama were examined. Variables found to have a relationship to program outcome were age and race. The youngest age groups (17 - 24) were found to have a lower success rate in LPN programs (Parrish, 1994).
Demographic characteristics and academic variables of graduates from an urban practical nursing program were studied by Young-Richardson (1996) to assess the extent that these characteristics could predict students' performance on the NCLEX-PN. The sample consisted of 261 practical nursing graduates who wrote the licensure examination between 1982 and 1987. The seven demographic independent variables included gender, age, high school graduate or GED, prior nursing experience, employment status while enrolled, marital status, and number of children under age sixteen. Practical Nursing Entrance Examination (PNEE) scores, National League of Nursing Achievement Test scores, grade point average at end of pre-clinical experience, and grade point average at program completion were the academic variables studied. The researcher chose multiple linear regressions to analyze the data. The results of the study indicated that students with minor children under age sixteen in the students' families had higher NCLEX-PN scores, and this variable accounted for six percent of the variance in NCLEX-PN, demographic variables were not considered predictors of success on the NCLEX-PN and 69% of the variance in NCLEX-PN performance is explained by scores on four NLN Achievement Tests scores and by scores on the PNEE (Young-Richardson, 1996).
Snook (1997) studied eight classes of practical nurses over the years 1990 to 1995 for the purpose to identify predictors on the basis of cumulative grade point average and program completion among low-income practical nursing students. Both groups were studied separately. Data analysis included description of both low-income and non-low income groups on demographic characteristics of age, gender, marital status, full or part-time student, high school or GED, post high school education, and years of previous employment, sychological Services Bureau (PSB) aptitude test scores, program completion, and final grade point average. Both the t test and chi-square test were applied to determine similarities and differences in the two groups. Predictive formulas were also developed from a step-wise multiple regression analysis. The researcher found that among the low-income group, married students were more likely to graduate than single students. Regarding final grade point average, scoring high on the PSB verbal subtest had a positive correlation with final grade point average for both low income and non-low income groups, and the variables part-time and married increased the likelihood of a student receiving a higher final grade point average.
Predicting program completion and NCLEX-PN success for remedial and non-remedial practical nursing students was the focus of the research conducted by Hawsey (1997). Chi-square tests and logistic regression were used to analyze the following independent variables that include race, method of high school completion, participation in remedial coursework, cumulative number of nursing courses failed, and language. The findings demonstrated that in order to pass NCLEX-PN on the first attempt was influenced by reading ability measured by ACTASSET placement examination scores, race, and cumulative nursing GPA. Program completion was influenced by age, as older students were less likely to graduate than younger students, and number of nursing courses failed. As the number of nursing courses failed increased, the likelihood of graduation decreased. The study results demonstrated no statistically significant relationship between the ASSET subtests in writing and numerical skills and first time NCLEX-PN licensure. A particular significance to this study is that Hawsey found no difference between program completion rates of students who had undergone remediation prior to starting the nursing program compared to those who had not participated in prior remediation. This finding suggests remediation programs are successful in preparing students with academic deficiencies for the demands of a practical nursing curriculum (Hawsey, 1997).
Ostrye (2000) study explored whether differences in licensure rates existed among Ivy Tech State College's 16 practical nursing programs included in the study. The NCLEX-PN results and academic records of 114 practical nursing students were examined using forward inclusion logistic regression procedures. Results of a chi-square analysis indicated there was a statistically major difference between NCLEX-PN licensure rates among Ivy Tech State College's 16 practical nursing programs when comparing the combined smaller nursing programs to each of the larger programs (Ostrye, 2000).
Boudreaux (2006) found that U.S. educated students were more likely to drop out or fail the practical nursing program however; those graduating were more likely to pass the NCLEX-PN. A foreign high school education, preadmission Writing skills, and GPA contributed significantly to prediction of completion of the nursing program. A U.S. high school education, male gender, and preadmission reading and writing skill level contributed to success in predicting results of the NCLEX-PN for program graduates (Boudreaux, 2006).

NCLEX-RN Predictors of Success
The NCLEX-RN success rates of nursing programs are good indicators of how many new RNs are entering the nursing profession and the healthcare workforce. Hence, examining the relationship between admissions criteria and success on the NCLEX-RN may identify at-risk students for performing poorly on this exam. Baker's (2008) conducted an investigation to determine if a relationship existed between the number of admissions and selection requirements required by a program and first-attempt NCLEX-RN success. The study participants were 10 community colleges' ADN programs in the state of Arizona. The researcher first examined the various admission requirements and admission processes used by these different programs. Second, the first-time NCLEX-RN pass rates of the 10 ADN programs were examined. Finally, an analysis was made to determine if a relationship existed between the number and make-up of admissions and selection requirements of 10 nursing programs and their first time NCLEX-RN pass rates. Other programs admissions requirements included standardized testing, interviews, and a Certified Nursing License. Findings of the study indicated that programs with more pre-requisite and admission requirements did not exhibit better NCLEX-RN success compared to programs with less prerequisite and admission requirements. Nursing programs requiring more science pre-requisite courses did not demonstrate higher first attempt NCLEX-RN success rates than programs with fewer science prerequisite courses. Further, programs using standardized tests with a minimum cut score did not demonstrate superior first-attempt NCLEX-RN pass rates compared to the one program without standardized testing as part of their admissions criteria (Bakers, 2008).
Crow et al. (2004) conducted a national study using a survey that resulted in 160 responses from BSN programs in 38 states. The two-fold purpose of the study was to identify what program requirements and interventions were being used by BSN programs to promote NCLEX-RN success and to determine predictors of NCLEX-RN success. The nursing programs participating in the study were considered exemplary because the NCLEX-RN pass rate (87.37%) in 1999 was above the national average (84.72%). The survey tool used by Crow et al. (2004) took approximately 30 minutes to complete and consisted of questions geared towards obtaining data to achieve the purpose of the study. Questions related to program admission requirements included ACT scores, SAT scores, cumulative pre-admissions GPA, and standardized entrance exams. Students' abilities to progress through nursing programs were also assessed, as only graduates of nursing programs are allowed to take the NCLEX-RN. Questions related to criteria for progression through the nursing program included course grades, standardized exams, clinical performance, and cumulative GPA. NCLEX-RN readiness questions focused on course specific readiness exams and comprehensive assessment exams. The study did not indicate which standardized entrance exams were used by the various programs (Crow, 2004).
Grzegorczyk's (1994) nationwide study involved LVN students enrolled in five different ADN programs located in five different states. The ADN programs were not randomly selected but were chosen because they were members of the National Alliance of Community and Technical Colleges. The predictors of success for LVNs enrolled in associate degree nursing programs were investigated in this study. Success in this study was defined by two outcome measures: ADN program completion, and NCLEX-RN success. The study attempted to determine the success measures by asking three questions. Results from the study concluded that length of LVN work experience and type of LVN work experience (acute care experience) was the only student characteristic and admissions criteria to predicted program completion and licensure success. ADN program that predicted success among LVN students included number of full-time faculty, program budget, NLN accreditation. No institutional characteristic predicted success among LVN students. Findings of the study led Grzegorczyk to assert that admissions criteria did not predict LVN-to-RN success or completion rates, but instead served as a barrier to LVN success in ADN programs (Grzegorczyk's, 1994).
Sayles et.al (2003) conducted a study to determine if a relationship existed between scores on standardized exams and first-attempt success on the NCLEX-RN. The standardized exams examined were the NET and the PreRN exam. The NET exam was taken by students upon admission to the nursing program, while the PreRN exam was completed during the final semester of the nursing program, before taking the NCLEX-RN. The NET provides a wide range of information on the test taker including math and reading ability and profiling information such as learning styles and the level and types of stressors of the test taker. Data obtained included NCLEX-RN results, demographic data, ACT and GED scores, program admission GPA, overall nursing GPA and number of RN courses repeated while enrolled in the program. Findings from the study revealed that minority students were not as successful on the NCLEX-RN. Other outcomes obtained from the study were that individual (math and reading) and composite NET scores, in addition to composite PreRN examination scores were all predictors of NCLEX-RN success. Further, higher program admission and overall nursing school GPAs were found to result in an increased likelihood of NCLEX-RN success (Sayles et.al, 2003).
Seldomridge and DiBartolo (2004) attempted to identify predictors of NCLEX-RN success and failure at various points in a nursing program. Data were obtained by reviewing student records and NCLEX-RN report. Independent variables included prerequisite nursing admissions criteria variables, cumulative GPA in junior year and number of 'C' grades in senior year. Course grade in Pathophysiology was the only pre-admissions criteria to produce statistically significant results. These variables predicted NCLEX-RN success 98.7% of the time, and failure 5.6%. Students who were unsuccessful on the NCLEX-RN were noted to have twice as many 'C' grades in junior level nursing courses. However, the comprehensive exit exam, the National League of Nursing Comprehensive Achievement Test for Baccalaureate Students (NLNCATBS) given to seniors was the most accurate overall predictor of NCLEX-RN success and failure rates. Performance on the NLNCATBS exam predicted NCLEX-RN success 94.7% and failure 25% of the time. NCLEX-RN failure was more difficult to predict and generally less accurately predicted (Seldomridge & DiBartolo, 2004).
McGahee et.al (2010) initially examined nine academic variables to determine if these variables were predictors of first-attempt NCLEX-RN success. Initial data collection led to changes in the programs curriculum and admission policy and as faculty noted trends common to students who were unsuccessful on the NCLEX-RN. In 2007, changes were also made to the study's methodology. Instead of nine independent variables, the study streamlined the independent variables to three. Findings of the study indicated success in Pathophysiology, the Theoretical Foundations course and scores on RN Assessment Test were all individual predictors of first-attempt NCLEX-RN success. However, combinations of the three independent variables increased their predictive power to determine NCLEX-RN first-attempt. The combined effects of the RN Assessment Test score and the Pathophysiology course resulted in the strongest predictor of NCLEX-RN success. Further, pre-requisite science GPA when combined with any of the other independent variables was a statistically significant predictor of first-attempt NCLEX-RN success (McGahee et.al, 2010).

Lynton and Thomas (1980) studied attempts to build university population programs and identified essential dimensions that led to an institution building theory and organization-environment diagnostic framework. Three key variables to be integrated within the framework are the nature of the environment, internal structure and processes, such as leadership, programs, and decision-making and a concept of the organization's primary purpose. There are supports from society through institution resources such as budgets and commodities; intermediate products such as leadership, doctrine, programs, internal structures, and linkages; and final products such as services, influences to society, and institutional reinvestments back to the university to facilitate more intermediate products. Common failings in linkages and linkage networks are functional imbalance, overload and conflict, and essential external and internal relationships (Lynton & Thomas, 1980).
A proactive stance is important for an organization's success, along with relatively high autonomy of the units on which the organization depends for its resources and for the use of its outputs or products. Lynton (1974) wrote about mapping as a guide to the development of any enterprise, but with a focus on universities, more specifically an attempt to develop a university population program. It is essential to look outward toward the community, policy makers, planners, and administrators, to determine a realistic perspective about what is needed and what is likely to be funded. No university program is close to its optimum size, but some programs exceed a size they can manage (Lynton, 1974). Interuniversity networks for collaboration are important elements. Lynton noted that many university programs have directors who are overloaded with work, but continue for long periods weak in key areas of program leadership, unclear of mission and structure, and short on linkages and policy formation. The programs are more the products of an unending string of crises. Three most important issues reside within functional university issues and are in the form of faculty appointment, financial relationships, and curriculum control (Lynton, 1974).
Yin and Burger's (2003) study examined the relationship between selected pre-requisite ADN admissions variables and first-time success on the NCLEX-RN. Study participants consisted of freshman students, transfer level students, students with previous degree, and LPN students. Variables studied included student status (such as transfer level student, previous degree student), cumulative college and high school GPA, GPA in program pre-requisite courses (such as English and biological sciences), standardized test scores (ACT), number of college credits taken, and demographic data such as age, ethnicity and gender at time of nursing program admission. The researchers determined that pre-requisite admissions college GPAs in biological science together with grades in psychology and high school class rank were the strongest predictors of first-attempt NCLEX-RN success. Statistical data from the study indicated that of the 325 ADN students in the study, eight were LPNs. First attempt NCLEX-RN success was noted in 285 students with all 8 LPNs passing on the first attempt. Contrary to the outcomes from previous studies, ACT composite scores and number of college credit hours were not found to be significant predictors of NCLEX-RN success (Yin & Burger's, 2003).

Wonderlic Scholastic Level Exam and Personnel Test
The Wonderlic was first published in 1937. There is no information in the test manual regarding how much the test has changed since its inception, nor is there information about the frequency and scope of periodic revisions. Initial development of the Wonderlic, as well as current interpretation, reflect a strong psychometric orientation. Both of these theorists presume the existence of 'g,' a general intelligence factor that is heritable and unchangeable. More recent theories of intelligence question this monolithic worldview, but especially the work of Robert Sternberg (1988) and Howard Gardner (1983). Sternberg emphasizes changeable adaption skills such as selection and shaping that enable one to improve one's intelligence. In contrast, Gardner emphasizes the role of eight autonomous intelligence 'modules' that each performs a specific intellectual function. Both theories question whether a general intellectual factor exists and, if it does, whether it can be measured reliably and validly with a 50-item instrument. None of these concerns are addressed in the test manual (Brody, 1992).
Various forms of essentially the same test are known as the Wonderlic Personnel Test (WPT) and the Scholastic Level Exam. The WPT in particular has a long history of use in employment settings, both personnel offices of companies and employment agencies. It was originally adapted from the Otis Self-Administering Tests of Mental Ability in 1938. It is not clear the extent to which the Scholastic Level Exam has gained usage in education, although it is employed by educational institutions to determine eligibility for federal financial aid and under the 'opportunity to learn'/'ability to benefit' criterion. Both employment and educational forms are essentially brief tests of general intelligence/general cognitive ability. The tests are composed of 50 multiple-choice or short-answer questions that are administered in 12 minutes. The test is rather highly speeded. Although it is also now available in a computer-administered version, it is primarily administered in a two-page, bifold test format. A test taker places one's name and certain demographic information on the cover of the test, opens the test, and all 50 items are in the interior of this two-page instrument. The test has been faulted previously for small print and it continues to suffer from this problem, except in the computerized version. Although the test is called self-administering, it is clear that its administration needs to be proctored, for both cheating and test security reasons. An individual's test score is simply the number of correct answers with no correction for guessing (Carroll, 1993).
Until the use of the WPT was challenged in several highly visible court cases, it enjoyed wide industrial use in making hiring decisions. It is very brief, its administration does not require a trained examiner, and it can be easily scored by the use of a key. Certainly, the above aspects are some of the reasons for its popularity and longevity. The test is intended as a general measure of intelligence, although that word is infrequently used in the manual. Even though, the manual reports that the test does not measure achievement per se, obviously substantial general knowledge is involved, including vocabulary and other aspects of developed abilities; some aspects, such as the interpretation of proverbs, appear surprisingly culturally loaded. The items are arranged by their level of difficulty, with the easiest items falling at the beginning of the test (Carpenter et.al, 1990).
Most tests of general mental ability involve both speed and power. Speed is clearly more important on the WPT than it is on most tests of this type. Murphy (1984) addressed the speediness factor on this test and its impact on specific candidates. Few candidates (less than 1%) generally even attempt the last 10 items on the test. The speediness of the instrument is likely to affect adversely those who are older, who have various kinds of disabilities, and those for whom English (or whatever language the instrument in which the test is administered) is not their primary language. Only if significant speediness on a job or in an educational experience is critical, does this fairly extreme level of speediness make sense. The manual provides score adjustments for age due to the speediness. For example, it is recommended that those between 40 and 49 years old receive two raw score points added to their score to balance the speediness factor. One other adjustment is provided for other factors that might influence a test taker's ability to take the test quickly; the manual states that if a test taker answers many questions correctly given a limited number of items attempted, a 'misassessment' may be diagnosed. To rectify this problem, another form of the WPT may be given in an untimed fashion, with 6 points subtracted from the resulting score. No justification for this computation is provided.
There are at least 10 forms of the WPT, including four identified as Scholastic Level Exam forms. In addition, large-print, Braille, and audiotape forms of the test are available for individuals with disabilities (Brody, 1992).

Completion of Nursing Program
Program completion is a required qualification to sit for the NCLEX-RN exam. Students who are not prepared academically may need to repeat courses, delaying program completion. Many programs allow students a certain number of course repeats prior to termination from the program. Siktberg and Dillard (2001) described a BSN programs policy change, which increased allowable course failure from two to three courses prior to program dismissal. The findings associated with this policy change lead to the determination that 85% of graduates who had failed the NCLEX-RN had failed at least two nursing courses. This finding resulted in the reinstatement of the two-course failure policy. Therefore, program completion and on-time program completion are important consideration for students and programs alike Siktberg & Dillard, 2001).
Kyle (2000) studied selected admissions data as a predictor of ADN program completion. LVNs made up 29 of the total 399 participants of the study. During the study period 54 students failed to complete the program because of academic difficulty and 26 did not complete the program due to nonacademic reasons. A total of 319 students successfully completed the ADN program. Pre-admissions data examined included LVN status, number of college level courses taken, number of preadmission science courses completed, number of pre-admissions courses repeated, and institution where admissions courses were completed. The researcher determined the prior nursing work experience as an LVN does not increase ADN program completion. However, students who completed more college-level course work, particularly science courses in conjunction with a higher overall pre-admissions GPA were more likely to complete the program. Kyle (2000) concluded further research was needed regarding admissions course repetition and the transfer of college credit taken in various educational settings as the homogeneity of the study population may have affected the outcomes noted in the study.
Phillips et al. (2002) study consisted of 5,007 ADN students enrolled in 20 different ADN programs over a 5-year period. The study was undertaken because of high attrition rates and subsequent decline in program completion rates at RN programs. The goal of the researchers was to develop a program admissions model that improved program completion rates, and decreased attrition rates. The study examined 50 variables grouped into one of three separate categories. The categories included dispositional factors, pre-requisite requirements, and program selection variables. Dispositional factors encompassed a variety of variables such as GPA, number of college course repetitions, science and other college courses, ethnicity, gender, and age. Prerequisite requirements included the number of pre-requisite courses, pre-requisite course GPA. Program selection variables included program selection method (lottery, points), health care work experience, interviews, prerequisite course repetition, and applicant letters of recommendation. Findings from the study produced a composite model of four predictors to improve program completion which were overall program admission GPA, college English GPA, core Biology courses GPA, and number of core Biology course repetitions. The comparison related to the repetition of core biology courses indicated that students who did not repeat any core Biology courses had the highest chance of program completion. However, students who repeated all core Biology courses twice had a 13% chance of completing the program. The results from this ADN Model Prerequisite Validation Study set the standard for many community college ADN programs in defining program admissions and subsequent candidate selection for entry into their programs (Phillips et.al, 2002).
Rogers (2010) conducted a qualitative study that identified factors influencing success at an ADN program that was a division of a university that offered a BSN upgrade to its ADN graduates. Participants in the study included a total of six students and three instructors. Student participants had successfully completed the ADN program, had passed the NCLEX-RN on the first attempt, and were presently enrolled in the RN-to-BSN portion of the program that was offered by the university. Instructors included in the study had numerous years of experience teaching at various levels of the university's program. The study involved face to face interviews requiring responses to specific questions. A significant finding derived from the study was the rigorous preadmissions criteria required for program admissions produced students with similar foundational knowledge and ability. Therefore, factors other than the admissions criteria influenced subsequent program completion, and NCLEX-RN success. The participants in the study (students and instructor) agreed that though no one factor contributed to success in the nursing program, the ability to manage stress and juggle multiple roles and responsibilities were important attributes (Rogers, 2010).
Zappaterreno's (2006) study investigated the predictive ability of admissions criteria based on a multi-criteria system and first semester nursing course grades in determining on-time program completion, and NCLEX-RN success at a ADN program. The study also sought to determine if the current point system being applied to evaluate student applications and acceptance into the ADN program was appropriate. The point system applied variable point amounts to the admissions criteria to determine acceptance into the program and is considered a more stringent admission approach compared to rolling admission. Higher point values were awarded to the science pre-requisite course grades, as those courses were thought to result in higher program completion rates. The study involved two cohorts of nursing students (60 students per cohort) admitted within the same year. Results from the study were found to be inconsistent and conflicting between the two cohorts of students in the study. Demographic data that included age, ethnicity, and country of origin were also collected. Results from the study determined that admissions criteria (such as prerequisite science GPA) and first semester course grades did not predict on-time program completion. The point system was not found to be an appropriate method for evaluating and accepting student applicants. However, no changes were instituted to the admissions criteria of the program as results between the two cohorts of students in the study were inconsistent. It was suggested that the two cohorts were not a large enough sample size to predict program completion using the point system (Zappaterreno's, 2006).

Nursing Intervention in Practice
Reviewed literature regarding nursing intervention in practice constituted seven clusters, which included ambiguous nursing terminology constraints, insufficient support of collegial infrastructure, need of nurses for older adults, constraining force of economics, situation of nurses in workforce, funding and legislation of programs and involvement of nursing in healthy people 2020 (Ramsburg, 2007).

Ambiguous Nursing Terminology Constraints
The first part of reviewed literature explored nursing constraints in the health care landscape that was dominated by computer-based taxonomies, and biotechnical priorities. There were poorly defined nursing terms inhibiting analyzing, conceptualizing, and interpreting studies. Nursing intervention content in many research reports was limited with respect to providing guidance for moving forward in practice. There was a preponderance of references in literature that addressed the importance of nursing presence and caring. The terms were poorly defined, yet were expected processes underpinned by professional and personal maturity and values on the part of caregivers. Studies attempted to analyze and differentiate between nursing terminologies such as nursing presence and caring, but noted that the overlapping of terms suggested a lack of confirmable differences (Hopkins, 2006). Conn et.al (2008) analyzed the amount of intervention detail reported in research on nursing intervention. Quantitative content analysis, normative analysis, and physical unit analysis, were utilized to study 141 articles of research published in 27 journals. Many reports were missing components related to intervention. The study findings indicated that only 27% of the reports provided sufficient detail to potentially replicate the studies or transform the interventions into practice. Frequently lacking in reports were linkages and theoretical frameworks for accurately interpreting studies (Conn et.al, 2008, p. 57).

Insufficient Support of Collegial Infrastructure
The second cluster of reviewed literature related to nursing intervention in practice within the conceptual basis of this study introduced the inadequacy of collegial infrastructure support to develop successful nursing research. Maas et.al (2009) conducted a case description of 17 nursing schools involved in the nursing research of gerontological. It was concluded in the research that there was a requirement of health care for older persons and the success of a school was influenced by the enrollment of extra nursing research faculty of gerontological. Junior faculty who did not hold doctoral degrees, but wanted to conduct research in gerontological nursing often did not receive the necessary colleague infrastructure support in order to develop their skills, experience, and productivity for successful research. Gerontological nursing studies tended to be completed by researchers working independently, but some less fortunate nursing schools were able to access outreach models extended by other schools that were georontological nursing research intensive, in order to support the preparation of nurse faculty and clinicians. Only 0.9% of the nurses had doctoral research degrees, yet the number of nursing studies published in peer-reviewed journals was at an all-time high (Maas, et al., 2009, p. 412).

Need of Nurses for Older Adults
The third part in the study group on nursing intervention in practice identified that the future health care requirements of older adults would consume more time from health care providers, and nursing schools were rejecting a significant number of qualified students who could potentially fulfill the need. Siccardi (2001) presented a profile of the older adult and increasing longevity. Siccardi emphasized that advanced practice nurses (APNs) in gerontology would be a more cost effective way to relieve the time pressure from physicians and other specialists. Problematic, however, was that APNs must first become registered nurses who had completed the bachelor's level of nursing education. According to a report by the American Association of Colleges of Nursing, 39,423 qualified applicants were denied acceptance into 550 baccalaureate entry-level nursing programs in 2009. Health care providers would need to spend more time caring for their older adult patients in the future, and an evidence base for nursing practice and care advocacy for all community residents was an unfulfilled social requirement. Gebhardt et.al (2009) reported that by Year 2030, it was estimated that one American in five will be over 65 years of age. The authors described a system of guidelines and evaluation developed by a school of nursing to prepare nurses graduating from their program to provide care to older adults in the community. The school developed a geriatric curriculum map, and encouraged faculty to use educational resources from the 2007 Hartford Foundation. A gerontological case study format following a client over a 30-year period was used in the curriculum (Gebhardt et.al, 2009, p. 246).

Constraining Force of Economics
The fourth part in this group on nursing intervention in practice presented economics as a constraining force when care was developed for individuals with limited means, which encompassed the older adult population. According to the American Association of Colleges of Nursing, the number of schools that reported having initiated budget cuts or that had insufficient budgets more than doubled from 14.8% in 2008 to 31.1% in 2009. The rejection of qualified nursing students was due to a 60.7% shortage of faculty and a 61% insufficiency in number of clinical sites for hands-on practice. No segment of the population should experience compromise related to health care, but economics has exerted a significantly constraining force against care being developed for individuals with limited means. The older adult population with multiple chronic illnesses and fixed incomes when costs are increasing has been the segment at highest risk for inadequate care. New nursing graduates were expected to enter their professions with adequate knowledge to care for patients of all ages, but it was also essential that entry-level nurses possess the requisite specialized skills and knowledge to care for geriatric clients because of their numbers in the population (Sadler, 2003).

Situation of Nurses in Workforce
The fifth cluster of reviewed literature within this group related to nursing intervention in practice examined the dynamics of nurses in the workforce. An account of a cross-sectional study by Letvak and Buck (2008) formulated a continued nursing education article to elucidate nurses about the factors which influenced the productivity of work and the level of intent of registered nurses to remain employed in hospitals as direct patient care providers. Questionnaire responses were obtained from three hospitals in the southern United States. Research was lacking on the needs, limitations, and capabilities of older workers. The registered nurses reported that 12.7% of the time they were unable to meet the needs of their patients. The researcher recommended sufficient and fruitful employees as decisive to the provision of appropriate care for hospitalized patients. A number of retired nurses returned to the workforce since the recent United States economic downturn. The nurses possessed the potential to perform as mentors for new nurses who graduated with a repertoire of classroom theory, but little clinical practice. Each could learn from the other. High levels of bedside job stress and the increasing acuity of hospitalized patients caused older experienced workers to be perceived as decreased in their productivity. It became incumbent upon leaders in nursing to create new job roles and assignments for the experienced older nurses to improve their ability to provide quality care.

Funding and Legislation of Programs
The sixth part in this group of reviewed literature related to nursing intervention in practice introduced legislation and funding as essential for the development of programs to educate sufficient caregivers to meet future needs. West (2004) noted in a published article the negative impact of the shortage in nursing and of managed care on the health care system. West reported that very little research provided solutions that the health system could initiate in order to recruit and retain nurses. There were indications that attempted measures had not made any long term difference in the satisfaction and attitudes of nurses. The nursing environments did not necessarily change and it was not long before another nursing shortage loomed. West also noted that the advent of computers to streamline patient charting only decreased the amount of time spent with patients, and that patient satisfaction rose when there was greater nurse contact. West advocated offering reasonable cost-containing and time-saving solutions to the alternatives that presently existed, and reported that nursing gained strength by rapport with patients. To respond to the rapidly increasing older adult population, attempts to provide funding to nursing programs emanated from various sources. Some schools began to add geriatric healthcare to their curricula, but there will not be sustainable change if people are expecting it to occur from the top down that is via legislation, the media, or institutional benefits (West, 2004, p. 347).
The trust patients have in hospitals correlates with their nursing care received. Although nursing graduates would be expected to enter the workforce familiar with the variety of provider teams with whom they would be collaborating, they also could find themselves included in health management programs conducted by telephone and videophone. Due to the fact that patients mostly do not succeed to recall significant components of medical recommendation, intensive outpatient monitoring, whether by telephone or videophone, increased early detection of potential problems and give admission to information of health, feedback on reported symptoms, and strategies to enhance compliance in order to improve outcomes and quality of life. Innovative assistive devices for self-care and locomotion have become more visible in the commercial arena. Mobility and cognitive impairments have lead to functional decline and opened the market for the development of sensors and telecommunication features to enhance safety and monitor health condition and overall well-being (Ofori, 2002).

Involvement of Nursing in Healthy People 2020
The seventh cluster in this group related to nursing intervention in practice introduced the importance of nursing involvement in the government's Healthy People 2020 program. Trossman (2008) wrote that the power of prevention was not a new message, and posed a reminder that Florence Nightingale promoted clean air and water as a means to control the prevalence of disease. In some impoverished communities, school nurses may have been the sole health care providers. Prevalent disorders seen in emergency rooms have been myocardial infarctions, strokes, chronic lung disorders, increasing obesity, and mental health issues. Emergency rooms saw the results of placing more emphasis on treating diseases and conditions than preventing them. End-of-life care and more strategies to ensure healthy aging were among the important topics discussed within the Healthy People 2020 program in its attempt to identify the largest group of people needing to be reached (Trossman, 2008).

Effective Strategies for NCLEX Success
NCSBN Board of Directors reconsiders the passing standard every three years in an effort to ensure minimum competence and safe practice by new nurse graduates. Modifying the passing score is meant to ensure that each candidate meets the minimum qualifications for a new nurse and can function in today's changing health care environment. The NCLEXRN and the NCLEX-PN are administered online, and each candidate has a unique exam. However, all exams follow the test blueprint so that the examination experience is equivalent for all candidates. It is important to understand the exam format and how the exam is scored. The length of the exam for each candidate, as well as specific test items, is determined by the candidate's knowledge level and ability to choose correct answers. Each test item is presented on the computer screen, and answers are processed immediately (Hopkins, 2006).
Passing the NCLEX is determined by logits, rather than a specific score or percentage of items answered correctly. A unit of 'logit' is determined by Rasch (1961) and Wright & Stone (1999) for calibrating items and measuring persons. It is a prediction of the probability of an event (in this case that a candidate will answer an item correctly) achieved by placing data on a logistic curve. Interval units in this measurement system have equal differences between each point on the scale. In the NCLEX examinations, logits provide a determination of a candidate's ability based on both the average difficulty level of the item as well as the average ability of the candidate to answer an item correctly (Wharrad, 2003).
The process of administering items based on the candidate's response continues until the computer can make a pass/fail decision with a 95% confidence level based on the candidate's ability estimate. The goal is to identify at what point the candidate is answering items correctly about half the time. In simpler terms, the exam provides a minimum of 75 questions for each candidate and a maximum number of 265, including nonscored experimental items. Candidates have up to six hours to complete the exam. After item 75 and each consecutive question, the computer calculates the standard error of measurement and estimates the candidate's competence. When this competence level is determined to be either at or above the passing standard, the computer shuts off and the candidate is successful. Similarly, if the candidate's competence level is determined to be below the passing standard, the computer will also shut off because it is improbable that this will be changed with additional testing (Jefferys, 2001).
A number of strategies are recommended to improve program success rates. First, it is important to start at the beginning, with the admission process. Focus on identifying and selecting those students who can be successful in the education program and on the NCLEX-RN. Identify predictors to ensure the admission of qualified candidates and create admission requirements focused on unique issues of a program's student population. For example, preadmission scores on reading and math assessments and grades in nursing prerequisite courses can indicate students who are at increased risk of program failure and failure on the licensure exam. The NLN PAX-RN, in conjunction with preclinical course GPAs, is predictive of program and NCLEX success. Some nursing programs use the HESI preclinical examination for this purpose (Nibert & Young, 2008). Other standardized exams can be obtained from the NLN Testing Services and Assessment Technologies Institute (Alameida et al., 2011). Track student progression and success throughout the program to identify unique factors related to past student populations. Determine which students are not successful in the education program and which are not successful on NCLEX. For example, the authors received grant funding to pay for weekly tutoring sessions for students to strengthen their test-taking and analysis skills and established counseling services to help students set priorities, manage stressors, and deal with personal issues. Ultimately, NCLEX success is the student's responsibility.
Encourage students to participate in study groups and tutoring sessions and to be open to suggestions for developing time-management skills. Students may need to consider altering work schedules, perhaps using summers to maximize work hours and limit working while school is in session. Ensure that the education program provides, along with content, opportunities for students to develop critical thinking and analysis skills. Develop the skills of reasoning, analysis, and interpretation through targeted questions during lectures, labs, and clinical experiences. Write critical thinking exam questions and conduct post-exam reviews to explain rationales for correct and incorrect options. Students should be queried, guided, encouraged to think, analyze, interpret, and apply previous knowledge, especially from pre- and co-requisite courses, as well as new content. In theory sessions, provide broad concepts and targeted exercise worksheets so students can access information and begin to make connections. Explore the best methods for helping students use information to think like a nurse. Review all course exams to ensure items are at the appropriate level of difficulty and adhere to the test blueprint. Review exams for grammatical errors (Ramsburg, 2007).
It is often advisable to create a test coordinator role to help faculty write test items and develop blueprints for all course exams based on the curriculum, content, and cognitive level expected in each course. If needed, faculty can attend continuing education seminars to increase test development skills (Halstead, 2013). It is important to distinguish the purpose of exams. Use frequent quizzes, with 10 to 20 questions, to ensure that students understand the content. Quizzes are not only used to assess knowledge, but to reinforce, correct, and deepen the student's understanding of the subject matter. Final exams serve as a summative evaluation of how well the students have retained the knowledge and skills that are emphasized as learning objectives. It is important that faculty not teach to the test. Doing so only measures a student's short-term memory, rather than the ability to comprehend, analyze, interpret, apply, and evaluate information (Nibert & Young, 2008).
Explore student answers during the debriefing and ensure that correct responses are clearly identified. Review the curriculum along with the detailed NCLEX test plan to ensure all essential elements are included. Develop a series of learning outcomes with specific achievement measures and establish regular, fixed time intervals to review outcome achievements. Use standardized exams to determine curricular efficacy, aggregating and analyzing data to determine curricular holes and weaknesses. Some programs allocate a portion of the course grade based on student scores on validated exams, but check with your state board of nursing, because this practice is prohibited or limited in some states (NLN, 2012). Consider developing test anxiety workshops. Many students identified as excellent in the clinical setting report panic levels of anxiety when taking. Students should be encouraged to schedule the NCLEX exam within the first three months of program completion. The chance of failure increases when students delay taking the exam (Bonis et al., 2007).
The students who take full-time jobs as graduate nurses prior to taking the NCLEX also tend to have higher failure rates. End-of-program test sessions are very helpful in promoting NCLEX test success. A number of NCLEX review books and other resources are used, and students are encouraged to review test items and provide feedback. The reviews are scheduled two or three times weekly with both an earlyday and evening option, with continuous reviews for three or four months after graduation. These sessions also address psychological preparation for taking the exam, a feature reported by students as integral in managing NCLEX test anxiety. Many faculty and nursing education programs encourage graduates to take formal NCLEX review courses. In addition, a number of companies provide NCLEX preparation with various features including computer-format exams, custom made exams, remediation programs, NCLEX-RN review programs, and immediate feedback regarding scores. Faculty understands the importance of preparing students for current nursing practice and for passing the NCLEX-RN. There is no definitive formula for test success. Rather, a variety of strategies are needed to accomplish this goal (Halstead, 2013).

Conceptual Framework
Associate degree and baccalaureate degree nursing schools were not exempt from the web of internal and external turbulence in the health care and educational environments. Their evolution had been continuous along with their efforts to survive as major components in the nursing care industry. The positive turbulence theory of Rolf Lynton described the achievement and enforcement of equilibrium among organizations and their internal and external environments. The three-step planned approach to change created by Kurt Lewin presented an operational model to maximize program success. The self-care theory of Dorothea Orem incorporated principles and skills to meet and improve upon community health care demands. The theoretical concepts of Lynton, Lewin, and Orem, combined well in the management of public nursing schools and other health-care organizations. Students and graduates could use their concepts in the management of their own careers. Communities could use the concepts to assess and adjust to health care demands, and to increase their pool of expertise in order to bring equilibrium between educational organizations and their environments. It was noteworthy that Missouri, one of the nation's more populous states, had a Year 2020 projection of needs that included a higher proportion of older residents requiring care. The nursing shortages in Missouri, along with the nation's economic downturn, created major management challenges for public nursing school directors and deans. They were consistently aware of the level of turbulence in their organizational structures and in their external environments, and were poised to create proper linkages in their own agencies, which were subsystems within the community healthcare system. It was imperative that their collective voices be heard by society, regulators, and others who could provide support to help them lead the way to a healthier Missouri.

The U.S. is in the midst of a nursing shortage which will only become more critical over the next decade as baby boomers age and require increased health care and more nurses reach retirement age. Not only do admissions need to increase, retention and graduation of those same students needs to occur. Educational institutions today emphasize recruitment and retention of students. This is crucial in nursing where the shortage of qualified workers increases as society in the U.S. continues to age. It becomes essential that coordinators and faculty understand and implement strategies, which will retain students but also assist them in becoming successful. If the students who are at risk can be recognized, then the interventions can be instituted whereby the student can overcome the deficits and be successful on the licensure examination. The solution to the shortage of nurses means that programs need to admit, retain, and graduate competent nurses to meet the needs of the workforce.
The literature reviewed in this chapter has examined factors that influence success in nursing programs, with emphasis on passing NCLEX licensure exams for both registered nurses and practical nurses. Research also revealed that certain courses could predict early difficulties and would indicate these students had a need for remediation or assistance in order to complete their program of study. Studies did not agree that age was a significant predictor. More studies were found at the baccalaureate level. Different studies found a significant correlation between nursing course GPA and success on the NCLEX. Studies differed on the significance of High School GPA, repeated coursework, age and SAT (verbal and math) scores. No correlation was found in any study between marital status, type A personality, gender and success on the NCLEX-RN. In various studies of NCLEX-PN programs, the majority indicated that preadmission assessments, race, as well as age were significant factors in determining success on the NCLEX examination. Studies differed on the significance of gender and marital status as predictors of success.


This chapter describes the process of data collection and analysis for the purpose of identifying predictor factors that will help selection committees of nursing programs to determine criteria of admissions which most accurately measure the potential for successful completion within the prescribed curricular timeframe. This study involves data collection from graduates of nursing programs regarding their student success in their prespective nursing program. It provides the research design, population information, instrumentation, research questions, statement on data analysis, and a description of the sample. This study will use questionnaires answered by graduate nurses recently employed in the Acute-Care, Skilled-Care or Long Term Care environments and therefore, the study is qualitative in nature. Not all programs require students to complete an exit examination at the end of course study, but a majority of programs do require a pre-licensure examination. Therefore, this study is concerned with the identification of the predictor factors that will help student nurses in successful completion of their nursing programs within the prescribed curricular timeframe.

Research Design
There are different research methods that can be used in the study in order to achieve the aims and objectives of the research. However, it is crucial to understand that the selection of the appropriate research design should be based on the nature of the research problem. There are two different approaches, qualitative and quantitative research methods that are commonly used in research. It should be noted that the qualitative researh methodology is considered the most appropriate research approach to answer the research questions that seeks new knowledge in the context of social phenomenon.
The primary purpose of this qualitative study is to determine the factors that help in predicting the success of students in nursing programs. In this study the researcher has used qualitative approach to gather the required information regarding the success of nurses after the completion of their prespective nursing programs. Both primary and secondary qualitative data was used in this study. Qualitative research is more subjective than quantitative research.
In this study the researcher used questionnaires as a means to gather the primary data from the chosen sample of nurses within the state of Missouri. However, it is difficult to gather data from nurses from the entire state but as the researcher has extensive network of contacts in the state of Missouri, he is able to gather the primary data through questionnaires from the new graduate nurses in three differing healthcare settings. These nurses were contacted through emails and were asked to participate in the study by completing the questionnaire. The researcher also provided the consent form in the emails to gather their approval of participation. Along with the consent form the researcher also explained the aims and objectives of the study to the contacted nurses.

Research Setting/Context
According to a projection by the U.S. Bureau of Labor Statistics (2009), more than 1 million new nurses will be needed in the workforce by 2016 to replace current nurses either retiring or leaving the profession. Despite the increase in enrollments into nursing schools, the supply of Licensed Practical Nurses and Registered Nurses does not meet the demand facing society.
An important part of the health care profession is the Licensed Practical Nurse (LPN) or the Licensed Vocational Nurse (LVN). Licensed Practical Nurses, under the direction of registered nurses or physicians, care for the sick, injured, or convalescent. With the acute shortage of registered nurses, these practitioners are vital to the workforce in the delivery of quality patient care.
The progression of nursing practice in Missouri models along the same continuum from the licensed vocational nurse (LVN), referred to as licensed practical nurse (LPN) in Missouri, to the doctoral prepared registered nurse. The vocational level of education is the basic education preparation for the LPN licensure examination: NCLEX-PN (National Council for Licensure Examination for the Practical Nurse). Practical nursing programs are offered at community colleges and technology centers approved by the Missouri Board of Nursing. This single board of nursing governs both the RN and the LPN in Missouri; whereas, other states, such as Texas, have one board governing both RN and LPN.
Admission to the majority of nursing programs is a 'selective' one, regardless of the location of the program offered: community colleges or other public higher education institutions. A selective admission process is due to the capacity restrictions of limited classroom availability, faculty size, and instructor-to-student ratios dictating the number of students that can be accommodated in nursing programs. The shortage of nursing faculty/educators runs concurrent with the shortage of nurses in the profession. Once admitted, retaining nursing students becomes a challenge, as well as preparing them for graduation and licensure to practice.
In an effort to maximize the possibility that a graduate of one of the state's LPN programs will be able to pass the licensure examination, the NCLEX-PN??, individual LPN program leaders have instituted various intermediate steps to assess a student's performance prior to entrance into the program and throughout the program. While these benchmarks are seen as an indicator of a student's ability to complete the program, limited research is available to suggest the degree to which various programmatic factors may positively correlate to a student's ability to successfully pass the State licensure examination, the NCLEX-PN.
The problem under investigation is the lack of success of Licensed Practical Nursing (LPN) graduates on the National Council Licensure Examination-NCLEX-PN in Missouri. A decline in pass rates on the nursing licensure examination was noted as a contributing factor to the nursing shortage. The purpose of the present descriptive-correlational study is identifying predictor factors that will help selection committees of nursing programs to determine criteria of admissions which most accurately measure the potential for successful completion within the prescribed curricular timeframe. The research questions under study are:
RQ1: Is there a viable and measureable set of predictor factors that can predict the success of students in a practical nursing program?
RQ2: Is there a measureable correlation between admission criteria of a practical nursing program and student attrition?
RQ3: Is there a measureable correlation between admission criteria of a practical nursing program and graduation rates?
RQ4: Is there one admission criteria that measures program success more effectively than any other?
RQ5: Is the nursing program overall GPA, A&P, NCPA, HESI exit exam, or cognitive ability the most accurate independent predictor of NCLEX-PN success?
Since nurses selected for interviews have been connected with different issues in nursing programs therefore, it is important that they respond sincerely to the researcher. The honesty of the participants has been assumed due to the fact that this research is dependent on the correct feedbacks from the nurses being interviewed. It will be by the researcher assumed that the nurses selected from Missouri can be generalized to nurses all over the U.S.
One recommendation for further study included an investigation into the relationships between specific content examinations in the NLN Achievement Tests and performance on the NCLEX-PN and for further data analysis to be conducted to determine if there are academic variables or demographic variables that stand alone as predictors of success on the NCLEX-PN. Information that could assist faculty to plan interventions that will facilitate student success on the NCLEX remains a great need for all nursing education programs.
Examination of relationships of demographic and academic variables to student performance in a laddered (basic vocational preparation to advanced registered nursing program) practical nursing (PN) and registered nursing (RN) education program was valuable in establishing research-based admission, progression and graduation criteria to ensure successful completion of the program and pass the licensure examination.

Research Sample and Data Sources
The population for this study was defined as all graduates who completed a practical nursing program. The students of nursing requested to participate in this study were from both private and public institutions. All students in the May 2010 graduating classes were invited to participate in the study. A convenience sample was used with all students who were readily available to participate. The reason for using convenience sampling method is to select those individuals for the study that are readily available. This kind of sampling method is suitable when there is a lack of budget or limitation of the time.
The sample for this study included 10 nursing graduates who completed a practical nursing program in the state of Missouri. However, it should be taken into account that the participants of the study were provided the consent form with the request to read it thoroughly as it does not only explain the aim and objectives of the study but it also provides the participants about their rights to participate in the study as well as to quit their participation at any phase of the study. The intention of the researcher to provide the aims and objectives in the consent form of the study is to enhance the understanding of the participants about the topic the research so that they can better provide the most accurate and desired responses. In addition to it, consent form was used to make sure that the participants were contributing in the study purely on the basis of their own will and that there is no external pressure or influence from the researcher on the responses of the participants.
After selecting the participants, interviews was conducted this was in-depth. Furthermore, interviews were conducted via semi-structured questions. Not only the already prepared questions be thrown at the participant. But the questions were derived from the answers. This would be done in order to understand the rationale behind the answer. Since the subject of the paper is such that it forces the paper to depend largely on the primary information, therefore, a majority of the information infused in the paper was rendered via answers by the participants. Reliance on secondary sources was kept minimal in order to build the research from where it tends to exist today.
The interviews were conducted in a private online Skype sessions, only in the presence of the researcher and the participant. This was done to ensure that participant is able to express him or herself to the fullest to minimize the element of any biasness in any form. The secondary information was also collected from the trusted sources and certain electronic databases. The help of existing research papers and research journals were also taken to help the cause of study. After collecting the data, a theoretical is intended to be established to gauge the predicting factors in the success of students in a practical nursing program.

Instruments and Procedures
Under the qualitative research methodology, the research instrument which has been used by the researcher is interviews. For the convenience of the participants, the researcher has chosen to use Skype as a medium for conducting the interview which seems to be feasible for both interviewer and the participants.
In this study the researcher conducted interviews from the 10 nursing graduates who completed a practical nursing program in the state of Missouri to describe the predicting factors in the success of students in a practical nursing program. Only 10 interview participants were selected through convenience sampling method for this interview from the state of Missouri. These nurses were selected due to the extensive network of contacts of the researcher, particularly, in the state of Missouri.
As this study is based on both primary and secondary data the researcher has collected both data separately. The secondary data was gathered through the past publications and articles regarding the topic of the study. Various past publication and magazines were thoroughly examined to understand the predicting factors in the success of students in a NCLEX-PN. Data collection was also aimed to find the relationship between admission criteria of a practical nursing program and student attrition, the relationship between admission criteria of a practical nursing program and graduation rates, and explore one admission criteria that measures program success more effectively than any other. Additionally, interview analysis helped in understanding whether the nursing program overall GPA, A&P, NCPA, HESI exit exam, or cognitive ability is the most accurate independent predictor of NCLEX-PN success.
Prior to commencement of the interview process, the researcher spent time establishing rapport and putting the interviewee at ease. Establishing this rapport was important because it allowed the participants to become comfortable and at ease with the researcher. Online interviews through Skype occurred at the most convenient time and location for the participants. Since schedule of nurses were strict therefore all the nurses were not available at the same time. Thus, the interview times were flexible. All interviews for convenience took place online and the video interviews were recorded for analysis of the data.

Data Collection
A qualitative approach was appropriate for this research study because the variables being explored are unknown and can be explored through the responses given by participants. Qualitative research permits the researcher to conduct a detailed assessment of situations that arise naturally in social life. Understanding the lived experiences of a group of people through a discovery process like the interview method is a central feature of a qualitative research design.
The data collection process in this research involved several stages. The researcher divided the entire research into various stages which helped the researcher in collecting data in a systematic order. The stages of data collection were designed to have a systematic flow where the researcher could gather the required data in a well-organised manner. In this study the researcher divided the data collection process in three stages. These stages are explained below.
' Step 1: The first step of the data collection process comprises of formulation of research questions and aims and objectives. In this step the researcher has put down the general plan of the research study. In this stage the researcher collected the fundamental information on the subject of the research topic and developed the problem statement and the general outline of the study. The researcher also decided the appropriate research method for this study in this stage.
' Step 2: The second stage of the data collection process involves accessing different online publications, articles and journals to collect the relevant secondary data for supporting the research aims and objectives. The primary category explored in the research literature was predictors of success in the education of practical nurses for the NCLEX-PN. The predominant focus of the literature review was on research directed at identifying programmatic factors, academic and non-academic, for success on licensure examinations for the practical nurse.
' Step 3: In the third stage the researcher conducted an interview from 10 nursing graduates who completed a practical nursing program in the state of Missouri to describe the predicting factors in the success of students in a practical nursing program. Only 10 interview participants were selected through convenience sampling method for this interview from the state of Missouri. These nurses were selected due to the extensive network of contacts of the researcher, particularly, in the state of Missouri.

Data Analysis
In this study the researcher analyzed the secondary and primary data through qualitative research approach. The data from the interview was analyzed and presented in the narrative form in the discussion part of chapter 4. In this study the interviews were used to summarize data related to the various variables that emerged during the interview process. These variables or themes were analyzed by the researcher and the analysis was presented based on these variables or themes.

Confidentiality of the Data
As this study involved conducting primary interview, the researcher made sure that the responses of the participants and their identity remain confidential throughout the research process. The actual online interview data was kept confidential by the researcher for the analysis purpose and after the analysis of the study the researcher destroyed the interview video.

Role of the Researcher
In phenomenology, the researcher transcends or suspends past knowledge and experience to understand a phenonmenon at a deeper level; it is an attempt to approach a lived experience with a sense of 'newness' to elicit rich and descriptive data (Merleau-Ponty, 1962). As an educator of and researcher with nursing students, it was necessary for the researcher to acknowledge and attempt to bracket those experiences. No participants had been a student, past or present of the researcher.
To enhance the quality of information it is essential that the data collected is accurate and reliable. According to the researcher, findings as well as conclusions mainly depend on the nature and quality of the information that has been included in the study as the researcher analyzes what he or she obtains through the responses of the participants as well as through the findings of the previously conducted studies. It should be taken into account that the phase of collecting information is even more sensitive in this particular study as the researcher has intention to include both primary as well as secondary information in the study.
Additionally, the results of the research may also show signs of biasness. This may happen due to the biasness of the sample participants included in the research. It may also happen due to the interference of the researcher in the process to produce the appropriate results according to his/her understanding and will. The chances of the researchers being biased and the probability of them being interfering with the data are always wide and open. The researcher's role was to remain as an author and not to provide biased opinion about the research topic. The role of the researcher was also to remain careful not to violate the legal regulations pertaining to the research process, by doing so the researcher will be able to effectively conduct the research.
The collection of data from different people may also be considered as an exposure of their personality or privacy. The participants of the research may also consider some questions as interference in their privacy. To avoid any kind of misunderstanding, the role of the researcher is to explain the purpose and aim of the study to the participants.

Methodological Limitation
As the study involved multiple factors and players, therefore there are certain constraints which are bound to have an impact on the overall workflow and the results of the study. It is important to identify those factors which tend to limit the amount of data which can be collected. As an academic project, this study is bound by the time limitation. Since the time allowed to construct the research was limited therefore due to which results suffered. Another hindrance which had the impact on the findings and recommendations of the research is associated to access to information. Furthermore, the efforts were also made to eliminate the notion of biasness, thus, biasness in any form could impact the study. Therefore, it is the duty of the researcher to come up with various ways to eliminate this notion.

Ethical Concerns
The researcher was well aware of the ethical aspects of research and therefore certain steps were taken to ensure the ethical data collection and conduct of study. Firstly, the researcher used consent forms and emailed them to the respondents so that the participants can sign their voluntary participation in the study. The consent form explained clearly that the participation will be voluntary and that the participants will be able to withdraw from the study at any stage. Another ethical conduct was the confidentiality and anonymity of the participants.
The ethical conduct of research also measured the degree of accuracy and precision of the data collected. The information should be carefully recorded and documented according to research design to reduce the possibility of error. Document means recording, summarizing and / or encoding the information for future use.

Chapter 3 provides the research method used for conducting this study. Chapter 3 of this dissertation involved the research method which is adopted for gathering all the relevant information for this study. This chapter not only provides the kind of research method adopted but also presents the rationale for selecting a particular type of research method. A detailed description of the research techniques is also provided in this chapter that explains the ways in which the information is gathered or collected for this research.
The next chapter of this dissertation presents the findings of the study which were obtained from the qualitative methods. This chapter also presents the analysis and discussion about the findings of this dissertation. This chapter presents the analysis of all the data gathered or obtained from the secondary sources as well as interviews from the selected sample of nurses.


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