Please I would like a summary of this article not less than 200 words. Thank you.

390 Journal of Nursing Education

ABSTRACT

This study evaluated students’ demographic and nurs-
ing program variables and standardized test scores to
determine whether significant differences existed
between students who successfully completed the
National Council Licensure Examination for Registered
Nurses (NCLEX-RN®) and those who were unsuccessful.
In addition, the predictive accuracy of two standardized
examinations, the Mosby AssessTest and the Health
Education Systems, Incorporated (HESI) Exit
Examination were compared.

Two cohorts of graduating senior nursing students
were studied (1999 cohort N = 121; 2000 cohort N = 103).
Demographic and nursing program variables were
obtained from student records. The Undergraduate
Studies Committee provided standardized test scores
(Mosby AssessTest in 1999; HESI Exit Examination in
2000). Only two program variables were consistently
associated with success on the NCLEX-RN—final course
grade for a didactic, senior-level medical-surgical nursing
course and cumulative program grade point average.
Scores on both standardized tests were significantly dif-
ferent in students who were successful on the NCLEX-RN

and those who were not. The HESI Exit Examination
demonstrated greater sensitivity, specificity, positive and
negative predictive value, and test efficiency, compared
with the Mosby AssessTest.

Use of program variables and students’ standardized
test scores may allow faculty to identify students at risk
for failing the NCLEX-RN and to provide structured
remediation so these students may be successful on the
licensing examination and begin their nursing careers.

S
uccessful completion of national licensure examina-
tions is a key outcome for nursing graduates, as well
as an important and highly visible indication of

effective nursing programs. Fewer nursing students
across the United States are taking the National Council
Licensure Examination for Registered Nurses (NCLEX-
RN®), and those graduates who fail exhibit decreasing
likelihood of successful completion with successive
attempts (Dennis et al., 1990; Zuzelo, 1999). Recent
NCLEX-RN data demonstrate a steady downward trend
in successful completion for first-time candidates
(National Council of State Boards of Nursing, 2000). In
the United States, in 1997, 87.7% of graduate candidates
for licensure successfully completed the NCLEX-RN. In
1998, 85.0% of candidates were successful, and in 1999
and 2000, licensure was obtained by 84.5% of first-time
candidates. Only 82% of first-time candidates obtained
licensure after their first NCLEX-RN attempt in 2001
(National Council of State Boards of Nursing, 2000).

The decline in successful completion of the NCLEX-RN
is of concern not only for nursing graduates, faculty, and
administration, but also for those who employ nurses and
society in general. Nursing graduates must attain licen-
sure prior to beginning their nursing career, and failure of
the NCLEX-RN may produce both emotional and finan-
cial hardship for graduates (Poorman & Webb, 2000).
Although nursing programs evaluate the effectiveness of

Predictors of NCLEX-RN Success in a
Baccalaureate Nursing Program as a
Foundation for Remediation
Linda K. Daley, PhD, RN; Bonnie L. Kirkpatrick, MS, RN;
Susan K. Frazier, PhD, RN; Misook L. Chung, PhD, RN; and
Debra K. Moser, DNSc, RN

Received: April 28, 2002
Accepted: January 30, 2003
Dr. Daley is Assistant Professor, Clinical, Ms. Kirkpatrick is Clinical

Instructor, and Dr. Frazier is Associate Professor, Ohio State
University College of Nursing, Columbus, Ohio; and Dr. Chung is
Postdoctoral Fellow, and Dr. Moser is Professor and Gill Chair of
Cardiovascular Nursing, University of Kentucky, College of Nursing,
Lexington, Kentucky.

Address correspondence to Linda K. Daley, PhD, RN, Assistant
Professor, Clinical, Ohio State University College of Nursing, 1585
Neil Avenue, Columbus, OH 43210; e-mail: Daley.1@osu.edu.

DALEY ET AL.

September 2003, Vol. 42, No. 9 391

their programs with many criteria, licensure examination
success rates often are used as a broad indicator of pro-
gram quality. In addition, accreditation by the American
Association of Colleges of Nursing is based in part on
NCLEX-RN success rates of programs’ graduates. Given
the current and projected nursing shortage and its effect
on health care, it is imperative that educators identify
students at risk for failure to effectively intervene and
increase the likelihood of their success.

LITERATURE REVIEW

Prior studies identified a variety of predictors of
NCLEX-RN success for graduates of all types of nursing
programs, including associate degree, diploma, and bac-
calaureate degree programs (Arathuzik & Aber, 1998;
Barkley, Rhodes, & DuFour, 1998; Roncoli, Lisanti, &
Falcone, 2000). Campbell and Dickson (1996) found that
cumulative nursing grade point average (GPA) was the
best predictor of NCLEX-RN success. Parents’ level of edu-
cation and student’s age were the best demographic pre-
dictors of NCLEX-RN success in their meta-analysis of 47
studies of NCLEX-RN predictors (Campbell & Dickson,
1996). During a 9-year period, Mills, Sampel, Pohlman,
and Becker (1992) identified cumulative nursing GPA as
the best predictor of NCLEX-RN success in their sample of
generic baccalaureate students (N = 534) and described
admission criteria, pre-nursing GPA, and American
College Test (ACT) scores as the least helpful determi-
nants of NCLEX-RN success. Unfortunately, cumulative
GPA is calculated after completion of the program and
does not provide an opportunity for remediation.

Other investigators specifically examined variables
related to the nursing curriculum. McClelland, Yang, and
Glick (1992) found that in addition to pre-nursing GPA and
ACT scores, grades in the biological and social sciences and
chemistry were predictive of NCLEX-RN success in their
baccalaureate students (N= 1,070). Endress (1997) com-
pared predictors of NCLEX-RN success with White, Black,
and foreign-born baccalaureate graduates (N = 150). There
were no significant differences in NCLEX-RN pass or fail
rate among the three groups. In general, graduates who
were successful on the NCLEX-RN were more likely to
have a higher admission GPA, higher cumulative nursing
program GPA, and higher college final cumulative GPA
than graduates who were unsuccessful.

Alexander and Brophy (1997) reviewed 5 years of
NCLEX-RN performance and determined that Scholastic
Aptitude Test (SAT) verbal scores, nursing cumulative
GPA, and National League for Nursing comprehensive
achievement scores were the most significant predictors
of NCLEX-RN success in their sample of associate and
baccalaureate degree graduates (N = 188). More recently,
Roncoli et al. (2000) found that students with higher
grades in science and nursing courses were more likely to
be successful on state licensure examinations. Although
GPA and science grades are identified to differing degrees
as predictive of NCLEX-RN success in many studies,

other factors may significantly influence the success or
failure of graduates.

Inclusion of nonacademic factors, such as family
demands, finances, living arrangements, disorganization,
role strain, and lack of confidence, may be important con-
siderations in licensing examination success. Arathuzik
and Aber (1998) studied academic, as well as nonacadem-
ic, factors associated with NCLEX-RN performance
among baccalaureate students with diverse backgrounds
(N = 79). Of the academic variables studied, only cumula-
tive undergraduate GPA was significantly related to
NCLEX-RN success (p < .05). Among the nonacademic variables studied, English as the student’s primary lan- guage, family demands, emotional status, and a sense of test-taking competency were found to be significantly associated with NCLEX-RN success (p < .05).

A number of studies have examined the use of stan-
dardized achievement examinations to predict NCLEX-
RN readiness and likelihood of examination success.
Among these, the Mosby AssessTest was found to be a
moderate to strong predictor of NCLEX-RN success
(Ashley & O’Neil, 1991; Fowles, 1992; Jenks, Selekman,
Bross, & Paquet, 1989). Endress (1997) determined that
students with Mosby AssessTest percentile ranks below
21 were more likely to fail the NCLEX-RN than students
with ranks above this percentile rank. However, signifi-
cant disadvantages of the Mosby AssessTest include its
paper-and-pencil format, its length, and the time span
between test administration and the ability to review the
results. Recently, investigators have developed computer-
ized examinations that may be effective predictors of
NCLEX-RN success.

Lauchner, Newman, and Britt (1999) reported that use
of the Health Education Systems, Incorporated (HESI)
Exit Examination was a predictive indicator of student
success on the NCLEX-RN. This examination provided
immediate feedback to students in the form of a probabil-
ity score (i.e., probability of success on the NCLEX-RN)
and rationale for the correct answers for items missed.
The HESI Exit Examination was administered to gradu-
ates from associate degree (N = 1,976), diploma (N = 59),
and baccalaureate (N = 520) programs. The HESI Exit
Examination was determined to be predictive of success-
ful completion of the NCLEX-RN in 99.5% of cases when
the examination was monitored and 96.82% of cases when
not monitored. In a follow-up study (Newman, Britt, &
Lauchner, 2000), the investigators again determined the
HESI Exit Examination to be highly predictive of
NCLEX-RN success (98.3%). The investigators further
examined the NCLEX-RN success rate for students clas-
sified as low scoring on the HESI Exit Examination (i.e.,
probability score < 69%) and found that significantly fewer (p = .05) of these students failed when the HESI Exit Examination was used as a guide for remediation. Therefore, the HESI Exit Examination may be an impor- tant component of a remediation program.

The initial component of a comprehensive, structured
approach to remediation requires determination of valid

PREDICTORS OF NCLEX-RN SUCCESS

392 Journal of Nursing Education

and reliable indicators of the need for help. Therefore, this
study evaluated demographic and nursing program vari-
ables to determine whether differences existed between
students who were successful and unsuccessful on the
NCLEX-RN and compared the predictive ability of the
Mosby AssessTest and HESI Exit Examination in bac-
calaureate graduates who took the NCLEX-RN in 1999 and
2000. The research questions that guided this study were:

• Are there demographic variables (i.e., gender, age,
ethnicity, prerequisite GPA, ACT scores) associated with
successful completion of the NCLEX-RN?

• Are there nursing program variables (i.e., final
grades for chemistry, anatomy, sociology, zoology, patho-
physiology, and didactic and clinical senior medical-surgi-
cal nursing courses; final cumulative program GPA) asso-
ciated with successful completion of the NCLEX-RN?

• What is the predictive ability of standardized tests
(i.e., Mosby AssessTest, HESI Exit Examination) to iden-
tify students in need of remediation prior to administra-
tion of the NCLEX-RN?

METHOD

Design
In this ex post facto study, the demographic and acade-

mic characteristics of students who took the NCLEX-RN
in 1999 and 2000 and were successful or unsuccessful in
their initial attempt at the examination were examined
and compared. In 1999, the Mosby AssessTest was admin-
istered to graduating students, and in 2000, the HESI
Exit Examination was provided to graduating seniors in
the final quarter of the nursing program. The predictive
ability of these two standardized tests for NCLEX-RN
success also were examined and compared.

Sample
Data from two cohorts of generic baccalaureate stu-

dents were analyzed. The first cohort consisted of 121
graduating undergraduate seniors in 1999. The second
consisted of 103 graduating undergraduate seniors in
2000. In 1999, all graduating senior students were
required to take the Mosby AssessTest. In 2000, graduat-
ing senior students were offered the opportunity and
strongly encouraged to take the HESI Exit Examination.

Measures
Demographic and nursing program variables were col-

lected from student records. Variables were selected
based on the literature review and prior research find-
ings. Standardized test scores were obtained from the
Undergraduate Studies Committee. All data were placed
in a statistical spreadsheet for later analysis (i.e.,
Statistical Package for the Social Sciences 11.0).

Demographic Variables
Demographic variables included student age, gender,

and ethnic background, as identified by the student; pre-
requisite GPA; and ACT scores.

Program Variables

Program variables included in this analysis were stu-

dents’ earned grades for several prerequisite courses and
three nursing program courses. All courses were 10 weeks
in length. The students were admitted to the undergrad-
uate nursing program as sophomores, after completion of
prerequisite courses as freshmen. The prerequisite cours-
es included in this analysis were:

• One organic and one inorganic chemistry course (5
credit hours each).

• The human anatomy course (5 credit hours).
• The introduction to sociology course (5 credit hours).
• A zoology course that provided an introduction to

normal human physiology (5 credit hours).
Course grades were based on a 0 to 4.0 scale and are
equivalent to letter grades as follows: 3.8 to 4.0 = A; 3.4 to
3.7 = A–; 3.1 to 3.3 = B+; 2.8 to 3.0 = B; 2.4 to 2.7 = B–; 2.1
to 2.3 = C+; 1.8 to 2.0 = C; 1.4 to 1.7 = C–; 1.1 to 1.3 = D+;
.8 to 1.0 = D; and < .7 = E.

The nursing program course grades included in this
analysis were:

• The pathophysiology course that provided basic con-
tent about human pathophysiology (5 credit hours).

• The didactic, senior medical-surgical nursing course
that provided content about the care of adults with acute
and chronic multiple system physical illnesses, with con-
sideration of family, social issues, environmental systems,
and continuity of care (4 credit hours).

• The clinical senior medical-surgical course in which
students were provided with an intensive, precepted clin-
ical experience caring for adults with acute and chronic
multiple system physical illnesses (6 credit hours).
The final cumulative program GPA also was considered a
program variable in this analysis.

Standardized Test Scores
In 1999, students were required to take the Mosby

AssessTest, and in 2000, students were offered the oppor-
tunity and strongly encouraged to take the HESI Exit
Examination. Both standardized tests were administered
at the beginning of the students’ final quarter of the nurs-
ing program. The Mosby AssessTest is a multiple-item,
multiple-choice examination. This standardized, norma-
tive examination was administered as a paper-and-pencil
examination for 5 hours in a controlled environment.
Mosby scored the examinations, and after a period of
weeks, the results were reported to the faculty, who noti-
fied students of their earned scores. Results were report-
ed as raw scores, percentage of items correct, and per-
centiles. There were no established cutoffs for prediction
of success. However, the Professional Testing Corporation
(1999) since reported that 87% of individuals who scored
between 51% and 56% were successful on the NCLEX-
RN.

The HESI Exit Examination is a multiple-item, multi-
ple-choice examination. This examination used a blue-
print similar to that of the NCLEX-RN and was adminis-
tered in a controlled environment as a computerized

DALEY ET AL.

September 2003, Vol. 42, No. 9 393

examination lasting 4 hours. At the completion of the
examination, the computer scored the HESI Exit
Examination using the HESI Predictability Model
(Lauchner et al., 1999). Students received immediate
feedback and were able to meet with a faculty member to
discuss their individualized results at the completion of
the examination. Results were reported as raw scores and
probability of success on the NCLEX-RN.

Data Analysis
Means plus or minus standard deviations and/or fre-

quencies were used to describe sample characteristics. To
examine differences in demographic variables, program
variables, and standardized test scores between students
who successfully completed NCLEX-RN and those who
did not, independent t tests or chi-square tests were used,
depending on the level of measurement of the dependent
variable. The investigators were unable to perform a
regression analysis because of the number of variables
and the small number of students who were unsuccessful
in their initial NCLEX-RN attempt. The significance level
for this investigation was set a priori at p < .05. Bonferroni corrections were used where appropriate for multiple tests.

The sensitivity, specificity, positive and negative pre-
dictive values, and test efficiency of the Mosby AssessTest
and the HESI Exit Examination were calculated using
standard formulas (Figure). Sensitivity evaluated the
ability of the measure to predict failure on the NCLEX-
RN in the entire group, and the specificity evaluated the

ability of the measure to predict success on the NCLEX-
RN in the entire group. The positive predictive value indi-
cated the percentage of students predicted to fail the
NCLEX-RN who actually did fail, and the negative pre-
dictive value indicated the percentage of students who
were predicted to be successful on the NCLEX-RN who
actually did pass. The efficiency of the test was calculat-
ed as the percentage of time that the test provided the
correct prediction, either pass or fail. The cutoff used for
prediction of NCLEX-RN success was a rank at the 50th
percentile or greater on the Mosby AssessTest. For the
HESI Exit Examination, a cutoff for prediction of
NCLEX-RN success was a probability score of � 69%
(Newman et al., 2000).

RESULTS

Sample Characteristics
A total of 224 undergraduate seniors in two cohorts

participated in this study. No significant differences exist-
ed between the two cohorts (p > .05 for all variables). In
1999, the first cohort consisted of 121 students, who were
all required to take the Mosby AssessTest. In the Mosby
AssessTest cohort, 13 (10.7%) students failed the NCLEX-
RN on their first attempt. In 2000, the second cohort con-
sisted of 103 students. Eighty students voluntarily took
the HESI Exit Examination. In the HESI Exit
Examination cohort, 7 (6.8%) students failed the NCLEX-
RN on the initial attempt. However, only 2 students who
failed the NCLEX-RN also took the HESI Exit

Sensitivity of test = a/(a + c)

Specificity of test = d/(b + d)

Positive predictive value = a/(a + b)

Negative predictive value = d/(c + d)

Test efficiency = (a + d)/(a + b + c + d)

Figure. Calculation of the predictive value of the Mosby AssessTest and the HESI Exit Examination.

cell a cell b

cell c cell d

Failed Passed

Predicted to Fail

Predicted to Pass

PREDICTORS OF NCLEX-RN SUCCESS

394 Journal of Nursing Education

Examination. Demographic characteristics of these two
cohorts are presented in Table 1. Most students were
White women in their early 20s, who graduated with a
cumulative B+ average.

Demographic Variables
In the Mosby AssessTest cohort, several demographic

characteristics were significantly different between stu-
dents who were successful on the NCLEX-RN and those
who were not (Table 2). Students who were successful on
the NCLEX-RN were older (22.9 � 5.6 versus 20.4 � .9, p
< .001), had earned a higher prerequisite GPA prior to program admission (3.3 � .4 versus 3.1 � .3, p = .005), and scored significantly higher on the ACT (23.6 � 2.9 versus 19.6 � 3.4, p < .005). In the HESI Exit Examination cohort, ethnicity was the only statistically different variable between students who were successful on the NCLEX-RN and those who were not (Table 3). Thirty-three percent of the non-White students were unsuccessful on the NCLEX-RN, compared to 4% of the White students. However, the validity of this finding is questionable because so few non-White students were in the group.

Program Variables
In the Mosby AssessTest cohort, a number of program

variables demonstrated significant differences between
students who were successful on the NCLEX-RN and
those who were not (Table 2). Students who were success-
ful on the NCLEX-RN achieved higher final grades for
anatomy (3.2 � .6 versus 2.7 � .4, p = .009), pathophysi-
ology (3.3 � .5 versus 2.5 � .5, p < .001), and both the

didactic and clinical senior medical-surgical nursing
courses (didactic: 3.4 � .4 versus 2.8 � .6, p < .001; clini- cal: 3.5 � .5 versus 2.9 � .5, p < .001). Cumulative GPA also was significantly higher for students who were suc- cessful (3.4 � .2 versus 3.0 � .1, p < .001). Only two pro- gram variables demonstrated significant differences in the HESI Exit Examination cohort (Table 3). Students who were successful on the NCLEX-RN earned a higher final grade in the didactic portion of the senior medical- surgical course (3.1 � .6 versus 2.4 � .5, p = .004) and a higher final cumulative GPA (3.3 � .3 versus 3.0 � .02, p = .04).

Standardized Test Scores
In the Mosby AssessTest cohort, significant differences

existed in Mosby AssessTest scores (Table 2). Students
who were successful on the NCLEX-RN earned signifi-
cantly higher raw scores (93.8 � 10.7 versus 77.5 � 11.6,
p < .001), had a higher percentage of items correct (62.5 � 7.1 versus 51.5 � 7.7, p < .001), and a higher percentile rank (55.2 � 28.2 versus 19.7 � 19.3, p < .001). In the HESI Exit Examination cohort, students who were suc- cessful on the NCLEX-RN scored significantly higher on the HESI Exit Examination (67.6 � .2 versus 48.0 � .9, p = .002) (Table 3). Interestingly, students who voluntarily took the HESI Exit Examination were more likely to be successful on the NCLEX-RN than those who did not (p = .001).

The HESI Exit Examination demonstrated greater
sensitivity, specificity, positive and negative predictive
value, and test efficiency, compared to the Mosby
AssessTest (Table 4).

TABLE 1
Student Characteristics

Mosby AssessTest Cohort HESI Exit Examination Cohort
(N = 121) (N = 103)

Characteristic n (%) n (%)

Gender
Men 21 (17.4) 10 (9.7)

Women 100 (82.6) 93 (90.3)

Ethnicity
White 93 (76.9) 94 (91.3)

Black 8 (6.6) 4 (3.9)

American Indian 0 1 (1.0)

Asian 1 (.8) 4 (3.9)

Hispanic 1 (.8) 0

Missing data 18 (14.9) 0

Age* 22.7 � 5.7 22.5 � 5.1

Prerequisite GPA* 3.3 � .4 3.3 � .4

Final GPA* 3.4 � .3 3.3 � .3

* Values are reported as mean � standard deviation.

DALEY ET AL.

September 2003, Vol. 42, No. 9 395

DISCUSSION

The purposes of this investigation were to evaluate
selected demographic and nursing program variables to
determine whether differences existed between students
who successfully completed the NCLEX-RN and those
who were unsuccessful, to evaluate the usefulness of stan-
dardized examinations in the prediction of NCLEX-RN
success, and to compare the predictive ability of the
Mosby AssessTest and the HESI Exit Examination with
baccalaureate graduates who took the NCLEX-RN in
1999 and 2000. The results of this study suggest that few
demographic or program variables consistently were

associated with success on the NCLEX-RN. Both stan-
dardized examination scores were significantly different
in students who were successful on the NCLEX-RN and
those who were unsuccessful. When the standardized
tests were compared, the HESI Exit Examination provid-
ed greater sensitivity, specificity, positive and negative
predictive value, and test efficiency than the Mosby
AssessTest.

Many studies have evaluated predictors of NCLEX-RN
success in associate degree, diploma, and baccalaureate
program graduates (Alexander & Brophy, 1997;
Arathuzik & Aber, 1998; Barkley et al., 1998; Endress,
1997; Fowles, 1992; McClelland et al., 1992), but few pre-

TABLE 2
Comparison of Demographic and Program Variables and Mosby AssessTest Scores

by NCLEX-RN Success for all Students (N = 121)

Unsuccessful on NCLEX-RN Successful on NCLEX-RN
(n = 13) (n = 108)

Demographic Variables Mean �� SD Mean �� SD p Value†

Age 20.4 � .9 22.9 � 5.6 < .001

Ethnicity* .13
White 6 (75.0) 87 (91.6)

Non-White 2 (25.0) 8 (8.4)

Gender* .56
Men 3 (23.1) 18 (16.7)

Women 10 (76.9) 90 (83.3)

Prerequisite GPA 3.1 � .3 3.3 � .4 .005

ACT scores 19.6 � 3.4 23.6 � 2.9 .005

Program Variables

Chemistry 1 final course grade 2.9 � .7 3.2 � .6 .17

Chemistry 2 final course grade 3.1 � .6 3.1 � .6 1.0

Anatomy final course grade 2.7 � .4 3.2 � .6 .009

Social science final course grade 3.2 � .6 3.4 � .6 .2

Zoology final course grade 2.5 � .7 2.8 � .7 .13

Pathophysiology final course grade 2.5 � .5 3.3 � .5 < .001

Didactic senior medical-surgical final course grade 2.8 � .6 3.4 � .4 < .001

Clinical senior medical-surgical final course grade 2.9 � .5 3.5 � .5 < .001

Final cumulative program GPA 3.0 � .1 3.4 � .2 < .001

Mosby AssessTest Values

Mosby AssessTest raw score 77.5 � 11.6 93.8 � 10.7 < .001

Mosby AssessTest percentage of items correct 51.5 � 7.7 62.5 � 7.1 < .001

Mosby AssessTest percentile 19.7 � 19.3 55.2 � 28.2 < .001

* Values are reported as frequency and percentage.
† p values for nominal variables were derived from chi-square tests, interval or ratio level variables from t tests.
Note: Percentages for Ethnicity do not total 100% due to missing data.

PREDICTORS OF NCLEX-RN SUCCESS

396 Journal of Nursing Education

dictors have been identified consistently across studies.
In this respect, data from this study were consistent with
the literature. For both cohorts of students, only two pro-
gram variables were found to be associated consistently
with NCLEX-RN success. In the Mosby AssessTest cohort,
several demographic predictors (i.e., age, higher prerequi-
site GPA, higher ACT scores) and several program predic-
tors (i.e., final grades for anatomy, pathophysiology, and
the didactic and clinical medical-surgical nursing course;
cumulative program GPA) were found to be significantly
different in students who were successful on the NCLEX-

RN and those who were not. In the HESI Exit
Examination cohort, the only significantly different
demographic variable was ethnicity. Horns, O’Sullivan,
and Goodman (1991) found ethnicity to be predictive of
NCLEX-RN success. However, Endress (1997) compared
Black, foreign-born, and White baccalaureate graduates
and found no differences in NCLEX-RN success among
the groups. Because of the small numbers of non-White
students in this study’s sample, this finding is question-
able and requires further study with a larger sample of
non-White students.

TABLE 3
Comparison of Demographic and Program Variables and HESI Exit Examination Scores

by NCLEX-RN Success for all Students (N = 103)

Unsuccessful on NCLEX-RN Successful on NCLEX-RN
Demographic (n = 7) (n = 96)
Variables Mean �� SD Mean �� SD p Value†

Age 20.7 � 1.3 22.7 � 5.2 .33

Ethnicity* < .001 White 4 (57.1) 90 (93.8)

Non-White 3 (42.9) 6 (6.3)

Gender* .23
Men 0 10 (10.4)

Women 7 (100.0) 86 (89.6)

Prerequisite GPA 3.1 � .2 3.3 � .4 .3

ACT scores 12.0 � 10.0 16.1 � 10.1 .41

Program Variables

Chemistry 1 final course grade 2.6 � .3 3.0 � .6 .08

Chemistry 2 final course grade 2.8 � .5 3.0 � .7 .48

Anatomy final course grade 2.9 � .4 3.0 � .6 .56

Social science final course grade 3.2 � .4 3.4 � .6 .54

Zoology final course grade 2.2 � .9 2.7 � .7 .13

Pathophysiology final course grade 2.8 � .7 3.1 � .7 .32

Didactic senior medical-surgical final course grade 2.4 � .5 3.1 � .6 .004

Clinical senior medical-surgical final course grade 3.2 � .6 3.5 � .5 .09

Final cumulative program GPA 3.0 � .2 3.3 � .3 .04

HESI Exit Examination§ (n = 2) (n = 78)

HESI Exit Examination score 48.0 � .9 67.6 � .2 .002

HESI Exit Examination probability score 60.3 � 1.2 84.6 � 10.1 .001

Took HESI Exit Examination§ .001
No* 5 (71.4) 18 (18.8)

Yes* 2 (28.6) 78 (81.3)

* Values are reported as frequency and percentage.
† p values for nominal variables were derived from chi-square tests, interval or ratio level variables from t tests.
§ Of the 103 students in this cohort, only 80 chose to take the HESI Exit Examination.

DALEY ET AL.

September 2003, Vol. 42, No. 9 397

Significantly different program variables in the HESI
Exit Examination cohort were the didactic medical-surgi-
cal nursing course grade and the cumulative program
GPA. These findings are similar to many prior studies
that found higher science grades and higher grades in
nursing courses to be predictive of NCLEX-RN success
(Griffiths, Bevil, O’Connor, & Wieland, 1995; McClelland
et al., 1992; Waterhouse, Bucher, & Beeman, 1994).
Similar to earlier studies (Alexander & Brophy, 1997;
Campbell & Dickson, 1996), cumulative program GPA
was found to be predictive in both cohorts of students.
However, this variable does not provide a foundation for
remediation. Although admission criteria and nursing
program content were consistent for both groups, differ-
ences existed in demographic and program predictors of
NCLEX-RN success between the two cohorts. The major-
ity of variables used to predict NCLEX-RN success
appear to be inconsistent both in the literature and these
two cohorts. Continued investigation of these variables as
predictors is unlikely to be productive. It is probable that
other variables, such as test-taking ability, academic and
mental preparation, motivation, and response to stress,
are important to students’ success. These factors require
identification and investigation to determine their impor-
tance.

The Mosby AssessTest and the HESI Exit Examination
are standardized tests that have been used to predict
NCLEX-RN success in other studies (Arathuzik & Aber,
1998; Endress, 1997; Newman et al., 2000; Roncoli et al.,
2000). This investigation found that scores on both exam-
inations were significantly different in students who were
successful on the NCLEX-RN and those who were not.
There were differences in the numbers of students in each
cohort who took the standardized examinations. Students
who finished the program in 1999 were required to take
the Mosby AssessTest, and the college was able to provide
financial support for this endeavor, so all students partic-
ipated. However, in 2000, students who finished the pro-
gram were strongly encouraged to take the HESI Exit

Examination, but they were required to pay for the exam-
ination themselves (approximately $30). Therefore, only
80 students in this cohort took the HESI Exit
Examination. Surprisingly, the choice to take the HESI
Exit Examination was found to be significantly different
in students who were successful on the NCLEX-RN and
those who were not (p = .001). Students who chose not to
take the HESI Exit Examination (n = 23) may have felt
unprepared to take a comprehensive examination that
provided a probability of being successful on the NCLEX-
RN. The results would have provided concrete evidence of
their lack of preparation for the licensing examination.
Lack of financial support and time (4 hours) also may
have prevented some students in this cohort from taking
the HESI Exit Examination.

When the accuracy of the two examinations was com-
pared, the HESI Exit Examination demonstrated greater
sensitivity, specificity, positive and negative predictive
values, and test efficiency. This is the first study to com-
pare these two standardized tests in this way. The posi-
tive predictive value of both examinations was low
(Mosby: 19%, HESI: 22%). However, students who took
these examinations and were predicted to fail most likely
studied, took an NCLEX-RN review course, or prepared
in some way for the NCLEX-RN. Unfortunately, data
were not collected that describe this preparation. Test
efficiency (i.e., the percentage of time the test correctly
predicted success or failure on the NCLEX-RN) also was
greater for the HESI Exit Examination (Mosby: 60%,
HESI: 91%).

Based on the findings of this study, taking the HESI
Exit Examination currently is required of all graduating
senior nursing students at the college of nursing.
Students meet with a faculty member after completion of
the HESI Exit Examination to discuss their performance
and plan for remediation. In addition, the investigators
are in the process of developing a structured approach to
ensure students are prepared to take the NCLEX-RN
after graduation. Currently, students who receive less

TABLE 4
Measures of Accuracy for the Mosby AssessTest and the HESI Exit Examination

Mosby AssessTest HESI Exit Examination
Accuracy Measure (N = 121) (n = 80)

Sensitivity (i.e., percentage predicted to fail in entire group
who actually failed) 85% 100%

Specificity (i.e., percentage predicted to pass in entire group
who actually passed) 57% 91%

Positive predictive value (i.e., percentage of students predicted
to fail NCLEX-RN who actually failed) 19% 22%

Negative predictive value (i.e., percentage of students predicted
to pass NCLEX-RN who actually passed) 97% 100%

Test efficiency (i.e., percentage of time the test provided the
correct prediction) 60% 91%

PREDICTORS OF NCLEX-RN SUCCESS

398 Journal of Nursing Education

than a B– in any nursing course receive an invitation to
participate in a structured NCLEX-RN preparation inde-
pendent study course. The HESI Exit Examination is
administered halfway through this review. Based on the
probability score on the HESI Exit Examination, students
prepare a written plan of study, identify materials they
will use for preparation, and describe their strengths and
weaknesses. Data from this cohort of students will be
used to further develop this structured approach to stu-
dent preparation.

LIMITATIONS

This investigation has several limitations. The two
cohorts contained unequal numbers of students, and
there were fewer students in the HESI Exit Examination
cohort. Not all students in the second cohort (2000) took
the HESI Exit Examination. In addition, not all data
were available, in particular, data related to student age
and ACT scores. For example, older students and stu-
dents who transferred from other schools did not have
ACT scores in their student records.

The prevalence of NCLEX-RN failure is a concern with
the accuracy evaluation of these standardized tests (i.e.,
the Mosby AssessTest and HESI Exit Examination).
Prevalence in the population influences the positive and
negative predictive values calculated. If prevalence is low,
as with NCLEX-RN failures, the positive predictive value
tends to exhibit a number of false positives, and the neg-
ative predictive value tends to be close to 1.0. The preva-
lence of NCLEX-RN failure in the Mosby AssessTest
cohort was 10.7%, and in the HESI cohort, the failure
prevalence was 6.8%. Unfortunately, only 2 students who
failed the NCLEX-RN chose to take the HESI Exit
Examination, which lowered the prevalence in the group
analyzed to 3%. These findings must be considered with
regard to the prevalence of NCLEX-RN failure.

CONCLUSIONS

Considering the current and projected nursing short-
age and its effect on health care, nurse educators must
identify students at risk for NCLEX-RN failure to effec-
tively intervene and increase the likelihood of success.
Use of predictive program variables and scores from stan-
dardized tests, such as the HESI Exit Examination, allow
faculty to identify vulnerable students and provide reme-
diation so they may be successful on the NCLEX-RN and
begin their nursing careers.

REFERENCES
Alexander, J., & Brophy, G. (1997). A five-year study of gradu-

ates’ performance on NCLEX-RN. Journal of Nursing
Education, 36, 443-445.

Arathuzik, D., & Aber, C. (1998). Factors associated with
National Council Licensure Examination-Registered Nurse
success. Journal of Professional Nursing, 14, 119-126.

Ashley, J., & O’Neil, J. (1991). The effectiveness of an interven-
tion to promote successful performance on NCLEX-RN for
baccalaureate students at risk for failure. Journal of Nursing
Education, 30, 360-366.

Barkley, T., Rhodes, R., & DuFour, C. (1998). Licensure exami-
nation. Predictors of success on the NCLEX-RN among bac-
calaureate nursing students. Nursing and Health Care
Perspectives, 19, 132-137.

Campbell, A., & Dickson, C. (1996). Predicting student success: A
10-year review using integrative review and meta-analysis.
Journal of Professional Nursing, 12, 47-59.

Dennis, K., Edwards, S., Grau, W., Henning, E., Lee, B., &
Moses, D. (1990). Enhancing the success of NCLEX-RN
retesters. NursingConnections, 3(3), 43-50.

Endress, D. (1997). A comparison of predictors of success on
NCLEX-RN for African American, foreign-born, and white
baccalaureate graduates. Journal of Nursing Education, 36,
365-371.

Fowles, E. (1992). Predictors of success on NCLEX-RN and with-
in the nursing curriculum: Implications for early interven-
tion. Journal of Nursing Education, 31, 53-57.

Griffiths, M., Bevil, C., O’Connor, P., & Wieland, D. (1995).
Anatomy and physiology as a predictor of success in bac-
calaureate nursing students. Journal of Nursing Education,
34, 61-66.

Horns, P., O’Sullivan, P., & Goodman, R. (1991). The use of pro-
gressive indicators as predictors of NCLEX-RN success and
performance of BSN graduates. Journal of Nursing
Education, 30, 9-14.

Jenks, J., Selekman, J., Bross, T., & Paquet, M. (1989). Success
in NCLEX-RN: Identifying predictors and optimal timing for
intervention. Journal of Nursing Education, 28, 112-117.

Lauchner, K., Newman, M., & Britt, R. (1999). Predicting licen-
sure success with a computerized comprehensive nursing
exam. The HESI Exit Exam. Computers in Nursing, 17, 120-
125.

McClelland, E., Yang, J., & Glick, O. (1992). A statewide study of
academic variables affecting performance of baccalaureate
nursing graduates on licensure examination. Journal of
Professional Nursing, 8, 342-350.

Mills, A., Sampel, M., Pohlman, V., & Becker, A. (1992). The odds
for success on NCLEX-RN by nurse candidates from a four-
year baccalaureate nursing program. Journal of Nursing
Education, 31, 403-408.

National Council of State Boards of Nursing. (2000). NCLEX-RN
examination test plan for the National Council Licensure
Examination for Registered Nurses, effective date April, 2001.
Chicago: Author.

Newman, M., Britt, R., & Lauchner, K. (2000). Predictive accu-
racy of the HESI Exit Exam. A followup study. Computers in
Nursing, 18, 132-136.

Poorman, S., & Webb, C. (2000). Preparing to retake the NCLEX-
RN: The experience of graduates who fail. Nurse Educator,
25(4), 175-180.

Professional Testing Corporation. (1999). Reliability and validity
of Mosby’s RN AssessTest: Secured test 99. New York: Author.

Roncoli, M., Lisanti, P., & Falcone, A. (2000). Characteristics of
baccalaureate graduates and NCLEX-RN performance.
Journal of the New York State Nurses Association, 31(1), 17-
19.

Waterhouse, J., Bucher, L., & Beeman, P. (1994). Predicting
NCLEX-RN performance: Cross-validating an identified clas-
sification procedure. Journal of Professional Nursing, 10, 255-
260.

Zuzelo, P. (1999). Professional practice and the NCLEX exami-
nation: A bottom-line approach. Nurse Educator, 24(3), 11-12.