PREDICTION OF NURSING STUDENT PERFORMANCE 
IN FIRST YEAR COURSEWORK 
 
 
Except where reference is made to the work of others, the work described in this 
dissertation is my own or was done in collaboration with my advisory committee. 
This dissertation does not include proprietary or classified information. 
 
 
_________________________________ 
Lynn Purcell Norman 
 
 
 
Certificate of Approval: 
 
 
 
 
        
Maria M. Witte       James E. Witte, Chair 
Associate Professor       Associate Professor 
Educational Foundations,        Educational Foundations, 
Leadership, and Technology       Leadership, and Technology 
        
 
 
 
        
Margaret E. Ross       Stephen L. McFarland 
Associate Professor       Dean 
Educational Foundations,       Graduate School 
Leadership, and Technology 
PREDICTION OF NURSING STUDENT PERFORMANCE 
IN FIRST YEAR COURSEWORK 
 
Lynn Purcell Norman 
 
 
A Dissertation 
Submitted to 
the Graduate Faculty of  
Auburn University 
in Partial Fulfillment of the  
Requirements for the  
Degree of  
Doctor of Education 
 
 
 
Auburn, Alabama 
 
August 7, 2006 
 
 iii
  
 
 
 
 
 
 
 
 
PREDICTION OF NURSING STUDENT PERFORMANCE 
IN FIRST YEAR COURSEWORK 
 
 
Permission is granted to Auburn University to make copies of this dissertation at its 
discretion, upon requests of individuals or institutions and at their expense.  
The author reserves all publication rights. 
 
 
 
                                                                               
      Signature of Author 
 
 
             
      Date of Graduation 
 
 
 iv
 
 
 
 
 
 
 
 
 
VITA 
 
Lynn Norman was born January 11, 1955 in Montgomery, Alabama. She 
graduated from Robert E. Lee High School in 1973. She attended the University of 
Alabama and graduated from the University of Alabama at Birmingham with a Bachelor 
of Science Degree in Nursing in 1977. She received a Master of Science in Nursing 
Degree from the University of Alabama at Birmingham in 1983. After working as a nurse 
educator for eight years at Troy State University Associate Degree Nursing Program, an 
Education Consultant with the Alabama Board of Nursing for twelve years, and a nurse 
educator at Auburn University Montgomery?s Baccalaureate Nursing Program for two 
years, she entered graduate school at Auburn University in January 2003. She married 
Jeff Norman on May 24, 1975. They have two daughters, Kay and Karen; one 
granddaughter, Makenzie; one grandson, Braxton; and two grandsons on the way, Brewer 
and Braylen. 
 
 v
 
 
 
 
 
 
 
 
 
DISSERTATION ABSTRACT 
PREDICTION OF NURSING STUDENT PERFORMANCE  
IN FIRST YEAR COURSEWORK 
 
Lynn Purcell Norman 
Doctor of Education, Auburn University, August 7, 2006 
(MSN, University of Alabama?Birmingham, 1983) 
(BSN, University of Alabama?Birmingham, 1977) 
 
150 Typed Pages 
 
 
Directed by James E. Witte 
 
Abstract 
 
 
 
The nursing shortage affects nurses in clinical practice and those who educate 
students in nursing education programs. An influx of students seeking admission into 
nursing programs in combination with the shortage of nursing faculty has led to the need 
to determine early in the admission process which nursing students will be successful in 
the nursing program and which students will not. This study investigated the relationship 
between the score on a nursing pre-admission examination, HESI A
2
, and cumulative 
grades from prerequisite academic support courses as predictors of success in the junior 
year of a baccalaureate nursing education program. Demographic characteristics, nursing 
 vi
theory course grades, and learning style, personality profile, and behavioral factors from 
the preadmission examination were analyzed as predictors. 
This study was designed using a retrospective correlational approach to determine 
predictors of success in the junior year of a baccalaureate nursing education program. 
Data from one hundred twenty eight students seeking admission into the program were 
analyzed. There was a statistically significant correlation between the grade point average 
of the prerequisite academic support courses and the HESI A
2
 cumulative score for the 
sample. There was a statistically significant relationship with both the admission GPA 
and the HESI A
2
 cumulative score with success in the junior year of the nursing 
education program. Use of the cumulative GPA of the pre-nursing academic support 
courses and the HESI A
2
 as admission criteria was supported in this study. Demographic 
data showed too few participants in the sample to provide an analysis or an absence of a 
statistically significant difference between those who were successful in the junior year 
and those who were not. A statistically significant difference was noted between 
analytical and global learning styles in the group that was not successful in the junior 
year. 
 
 
 vii
 
 
 
 
 
 
 
 
 
ACKNOWLEDGMENTS 
 
 The author would like to thank those who made this endeavor possible. The 
encouragement of my committee members, AUM colleagues, and family led to the 
completion of the degree. 
I thank you Dr. James Witte for your encouragement and personal demonstration 
of teaching the adult learner. Dr. Maria Witte, thank you for your encouragement and 
attention to details. Thank you, Dr. Margaret Ross for your encouragement and 
enthusiasm for statistics.  
My AUM colleagues supported and encouraged me throughout the program. 
Thank you especially to Dr. Barbara Witt for your support and to the AUM School of 
Nursing faculty and staff. 
I am privileged to have family who prayed and encouraged me to complete this 
journey. This dissertation is dedicated to: my grandmother, Nell Brewer, who has 
supported me through all my degrees; my husband, Jeff, who was always there to love 
me and never wanted me to stop until it was finished; my mother, Nell Murphy, who was 
always delighted with my progress; and my daughters, Kay N. Welch and Karen N. 
Corley, who are relieved that it is finished. Finally, to Makenzie and Braxton, you now 
have my undivided attention. Thank you, God, for the doors You opened and the 
guidance through Your Word. 
 viii
 
 
 
 
 
 
 
 
Style manual or journal used: Publication Manual of the American Psychological  
Association, 5
th
 Editon.          
Computer software used: SPSS 11.5 for Windows, Windows XP, and Microsoft 
Word 2003           
 ix
 
 
 
 
 
 
 
 
TABLE OF CONTENTS 
 
LIST OF TABLES..................................................................................................... xii 
LIST OF FIGURES ................................................................................................... xiii 
I. INTRODUCTION ......................................................................................... 1 
Problem Statement......................................................................................... 5 
 Purpose of the Study ...................................................................................... 6 
 Research Questions........................................................................................ 6 
 Significance of the Study............................................................................... 7 
 Theoretical Framework.................................................................................. 7 
 Limitations of the Study................................................................................. 11 
 Assumptions................................................................................................... 12 
 Definition of Terms........................................................................................ 12 
 Organization of the Study .............................................................................. 14 
 
II. REVIEW OF LITERATURE??????????????????  16 
Introduction.................................................................................................... 16 
 History of Baccalaureate Nursing Education................................................. 18 
 Nursing Practice and Nursing Education....................................................... 25 
 Nursing Shortage ........................................................................................... 33 
 Assessment, Measurement, and Evaluation in Nursing Education................ 36 
 Prediction of Academic Success.................................................................... 41 
 Summary........................................................................................................ 50 
 
III. METHODS .................................................................................................... 51 
Introduction.................................................................................................... 51 
 Research Questions........................................................................................ 51 
 Participants..................................................................................................... 52 
 Variables of Interest....................................................................................... 53 
 Research Design............................................................................................. 56 
 Sampling ........................................................................................................ 58 
 
 Instrument ...................................................................................................... 59 
 
 x
 
  HESI Admission Assessment
TM
 (HESI A
2
)....................................... 59 
 
 Procedures...................................................................................................... 66 
 Analysis.......................................................................................................... 68 
 Summary........................................................................................................ 68 
 
IV. RESULTS ...................................................................................................... 70 
 Introduction.................................................................................................... 70 
 Participants..................................................................................................... 70 
 Research Questions........................................................................................ 73 
 
  Research Question One...................................................................... 73 
  Research Question Two ..................................................................... 75 
  Research Question Three ................................................................... 77 
  Research Question Four..................................................................... 82 
 
 Summary........................................................................................................ 90 
 
V. SUMMARY, DISCUSSION, AND RECOMMENDATIONS..................... 92 
 
 Purpose of the Study ...................................................................................... 92 
 Summary........................................................................................................ 92 
 Discussion...................................................................................................... 95 
 Recommendations.......................................................................................... 98 
 
  Recommendations for Further Research............................................ 98 
  Recommendations for Nursing Faculty ............................................. 100 
 
REFERENCES .......................................................................................................... 102 
 
APPENDICES ........................................................................................................... 116 
 
 Appendix A: HESI Admission Assessment 
TM
 (A
2
) ................................... 117 
 Appendix B: HESI Admission Assessment (A
2
) Faculty Scoring Guide ... 119 
 Appendix C: HESI Admission Assessment 
TM
 (A
2
) Scoring Information.. 123 
 Appendix D: Scoring Explanations for the HESI Admission  
  Assessment 
TM
 (A
2
) Learning Styles, Behavioral 
  Inventory and Personality Types ........................................... 125 
 Appendix E: Institutional Review Board (IRB) Selected 
  Nursing Education Program................................................... 134  
 
 Appendix F: Institutional Review Board (IRB) Degree  
  Granting Institution................................................................ 136 
 xi
 
 
 xii
 
 
 
 
 
 
 
 
 
LIST OF TABLES 
 
Table 1 Typical Course Placement in a Baccalaureate  
 Nursing Program by Semester ................................................................. 30 
 
Table 2 Enrollments, Applications Received and Accepted in  
 Generic Baccalaureate Programs by Year ............................................... 35 
 
Table 3 Classification for Potential Outcomes Using Sensitivity and Specificity 58 
 
Table 4 KR?20 for HESI A
2
 by Examination Component ................................... 64 
 
Table 5 Demographic Characteristics of Sample.................................................. 72 
 
Table 6 Comparison of Admission Grade Point Average and 
 Cumulative HESI A
2
 Score...................................................................... 74 
 
Table 7 Admission GPA and Outcome: Cutting GPA, Sensitivity 
 Specificity, and Predicted Probability...................................................... 77 
 
Table 8 HESI A
2
 Cumulative Score and Outcome: Cutting Score, 
 Sensitivity, Specificity, and Predicted Probability .................................. 80 
 
Table 9 Logistic Regression Analysis of Admission GPA and HESI A
2
............. 81 
 
Table 10 Percentage of Correct Prediction Based on  
 Admission GPA and HESI A
2
................................................................. 81 
 
Table 11 Frequencies of Demographic Characteristics by Outcome Group .......... 83 
 
Table 12 Comparison of Junior Year Nursing Theory Course 
 Grades by Group...................................................................................... 86 
 
Table 13 Comparison of HESI A
2
 Content Examination by Group ....................... 87 
 
Table 14 Frequencies of Learning Style Types by Group and Total...................... 88 
 
Table 15 Frequencies of Personality Types by Outcome Group ............................ 89 
 xiii
 
 
 
 
 
 
 
 
 
LIST OF FIGURES 
 
 
Figure 1 ROC Curve for Admission GPA.............................................................. 76 
 
Figure 2 ROC Curve for HESI A
2
 Cumulative Score............................................ 79 
 
Figure 3 ROC Curve for Admission GPA and HESI A
2
........................................ 82 
 
 
 
1 
 
 
 
 
 
 
 
 
 
I. INTRODUCTION 
 
A current shortage of practicing nurses has prompted nursing education programs 
to produce more nursing graduates for the workforce. Continuous publicity of the current 
job market for nurses and future nursing graduates has increased the number of potential 
students seeking admission into nursing programs (American Association of Colleges of 
Nursing [AACN], 2004; AACN, 2005; Johnson & Johnson, 2005). Parallel to the 
shortage of nurses in practice is the decreasing number of nursing faculty available to 
teach the increasing numbers of students (Hinshaw, 2001). Meeting the need for more 
nursing graduates in conjunction with the decreased number of faculty is a dilemma for 
nursing education program administration and members of the faculty. One strategy is to 
limit enrollment. However, limiting enrollment further adds to the shortage of nurses in 
practice. Faculty must seek ways to select students from the large pool of applicants who 
represent a reasonable prospect of success in the nursing education program and 
including successful completion of the national licensure examination for registered 
nurses. A method is needed for early identification of potentially successful students in 
the application process or early in the nursing education program.  
The shortage of practicing nurses and nursing faculty has resulted from various 
factors affecting the workforce. Buerhaus, Staiger, and Auerbach (2000) retrospectively 
analyzed the employment trends from the US Bureau of the Census Current Population 
2 
Surveys between 1973 and 1998. The study determined that during the 1960s and 1970s 
students, mostly female, who entered the nursing profession, were between the ages of 
fifteen to nineteen years. In the 1980s the group of students increased with age causing 
older students to enter nursing programs. Based on the age related patterns, Buerhaus, et 
al. (2000) projected the future trend of the nursing shortage to continue. By the year 
2020, the size of the registered nurse workforce will be approximately twenty percent 
below the forecasted need. While the focus of the Buerhaus, et al. (2000) study was the 
aging nursing population, women taking other job opportunities or choosing child rearing 
instead of employment added to the decrease number of nurses in the workforce (AACN, 
2003). 
Following the publicity and concern over the nursing shortage, nursing student 
applications to baccalaureate programs began to rise. The American Association of 
Colleges of Nursing?s (AACN) 2002 annual survey of baccalaureate programs showed an 
eight percent increase in enrollments over the previous year (AACN, 2002). Kathleen 
Long, president of AACN in 2002, complimented the nursing programs for bringing 
attention to the shortage and beginning to fill the gap (AACN, 2002).  
Factors contributing to the nursing shortage such as the aging workforce and job 
competition are identical to those affecting faculty positions. Hinshaw (2001) indicated 
that the decrease in the number faculty further adds to the nursing shortage because of 
limits placed on nursing enrollments. The report on 2003?2004 Enrollment and 
Graduations in Baccalaureate and Graduate Programs in Nursing from AACN (Berlin, 
Stennett, & Bednash, 2004) identified that 15,944 qualified baccalaureate nursing 
program applicants were denied admission in 2003 due in part to an insufficient number 
3 
of faculty. Furthermore, AACN (2005) reported that 32,797 qualified applicants were not 
accepted at schools of nursing in 2004 primarily due to a shortage of faculty to teach the 
students and resource restraints.  
Faculty, who teach in programs and prepare nursing students for professional 
nursing practice, are faced with a dilemma of deciding which students to admit into the 
nursing program and which to exclude. Identifying students who will be successful in the 
nursing program and on the National Council Licensure Examination for Registered 
Nurses (NCLEX-RN) has been the basis of several studies (Alexander & Brophy, 1997; 
Arathuzik & Aber, 1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; Brisco 
& Anema, 1999; Crow, Handley, Morrison, & Shelton, 2004; Daley, Kirkpatrick, Frazier, 
Chung, & Moser, 2003; Endres, 1997; Haas, Nugent, & Rule, 2004; Nibert & Young, 
2001; Nibert, Young, & Adamson, 2002; Sayles, Shelton, & Powell, 2003; Schmidt, 
2000; Seldomridge & DiBartolo 2004; Washington & Perkel, 2001). Few studies 
(Gallagher, Bomba, & Crane, 2001; Lewis & Lewis, 2000; Potolsky, Cohen, & Saylor, 
2003; Sandiford & Jackson, 2003) have identified factors that predicted success early in 
the application process or during the education process.  
Crow, Handley, Morrison, and Shelton (2004) surveyed 160 baccalaureate 
nursing programs across the United States to identify what data were used to predict the 
NCLEX-RN success. Ninety percent of the nursing education programs surveyed 
required a comprehensive end of program examination prior to graduation to predict 
those who would be successful on NCLEX-RN. Twenty-nine percent of those nursing 
programs surveyed used a cumulative grade point average (GPA) of pre-nursing courses 
plus the nursing theory and clinical courses to predict success on the licensure 
4 
examination. Approximately 36.3 percent of the programs used specific nursing course 
grades to predict success on NCLEX-RN. The data for these variables used for prediction 
were collected during the nursing program or immediately prior to graduation.  
Earlier identification of those likely to be successful in the nursing education 
program or pass the NCLEX-RN would be beneficial to faculty and the students. Crow et 
al. (2004) identified that baccalaureate nursing programs should contemplate using 
standardized entrance examinations as admission criteria to improve success in the 
program and the NCLEX-RN pass rates for their students. Although the NCLEX-RN is 
the decisive outcome for nursing graduates to become licensed, this examination is taken 
after graduation from the nursing education program.  
Attrition in undergraduate nursing education programs occurs throughout the first 
year of nursing courses and up to graduation. Astin (1991, 1993) identified factors 
affecting attrition in general education programs and categorized them into academic, 
student profile characteristics, environmental, psychological, and professional 
integration. These same factors relate to nursing education programs (Jeffreys, 2004). 
Progression policies in nursing programs determine which students continue in the 
program. Success in the nursing program is measured by nursing course grades. Success 
or failure in the nursing courses affects the nursing GPA and overall college GPA, which 
has a major effect on attrition (Jeffreys, 2004). Identification of those who are most likely 
to be successful early in the nursing education program would be more beneficial to 
faculty and the students. 
 
5 
Problem Statement 
With the overabundance of students seeking admission into nursing programs and 
a limited number of faculty available to teach the students, early identification of those 
students who will be successful in the nursing education program is imperative. 
Identifying students who would be successful early in the education process allows 
students who may not be candidates for admission into nursing programs to seek 
alternative career options. Additionally, early identification of at risk students can 
provide remediation strategies to be used at intervals during the process of completing the 
nursing program (Haas, Nugent, & Rule, 2004; Morrison, Free, & Newman, 2002; 
Nibert, Young, & Britt, 2003).  
Variables such as GPA on the pre-nursing courses have been used in many 
programs as the sole method of selecting students for admission. Health Education 
System, Inc. (HESI) has developed the HESI Admission Assessment
TM
 Examination 
(HESI A
2
) as an additional means to assist faculty in identifying students for admission. 
There is a limited amount of research on the HESI A
2
 and predicting success in a nursing 
program. This study adds to the body of knowledge and validation of the HESI A
2
. This 
study offers insight on screening criteria for pre-nursing students. The study also yields 
information to better prepare students accepted into the nursing program.  
Identifying a predictive pre-screening method for identifying those nursing 
students who will be successful in the nursing program is imperative for nursing faculty. 
Early identification of those students who will be successful in the nursing program will 
assist in meeting the nursing shortage and prevent unnecessary expenditures for the 
6 
student, such as tuition, books and supplies and for the nursing education program, such 
as faculty time spent on extensive remediation for potentially unsuccessful students.  
 
Purpose of the Study 
The purpose of this study was to examine the relationship between the 
prerequisite academic support courses for a nursing program and the HESI A
2 
as a 
predictor of success in the first year of a baccalaureate nursing education program. This 
study also identified demographic characteristics, nursing theory course grades, and HESI 
A
2
 based factors that can be used to predict first year student success.  
 
Research Questions 
   Four research questions were addressed in the study: 
1. What is the relationship between the admission GPA and the HESI A
2
 for 
nursing students? 
2. What is the relationship between the admission GPA and success in the 
first year of the nursing education program?  
3. What is the relationship between the HESI A
2
 scores and students who 
were successful in the first year of the nursing education program and those who were 
not?  
4. What demographic characteristics, nursing theory course grades, and 
HESI A
2
 based factors are predictive of success in the first year of the nursing education 
program?  
 
7 
Significance of Study 
There is a limited amount of research on the HESI A
2
 and predicting success in 
the first year of a nursing program and this study will add to this body of knowledge. This 
study will potentially offer insight on criteria used to screen students for admission into a 
nursing education program or identify students who may be at risk for being 
unsuccessful. A further potential result for this study is that it may yield information to 
identify and better prepare students who are enrolled in the nursing program for the rigors 
of the nursing curriculum. 
 
Theoretical Framework 
Astin?s (1991) input-environment-outcome (I-E-O) conceptual model for 
assessment was used as a guide for this study. The I-E-O model ?provides a powerful 
framework for the design of assessment activities and for dealing with even the most 
complex and sophisticated issues in assessment and evaluation? (p. 16). 
As a foundation for the I-E-O model, Astin (1991) discusses assessment as a 
means of research to assist educational programs in making decisions regarding student 
learning. The basic purpose of assessment from Astin?s perspective is to enhance the 
student?s educational development. According to Astin, assessment is the gathering of 
information regarding the performance of students. Assessment refers to two different 
activities: the collecting of information (measurement) and the use of that information for 
institutional and individual improvement (evaluation).  
Evaluation according to Astin (1991) is the rendering of value judgments. 
Evaluation of the information generated by a measurement incorporates making a value 
8 
judgment on the pedagogical methods or decisions for providing feedback to the student 
on the material presented. 
Assessment of students occurs throughout the college experience. Assessment has 
two purposes: to help select students (immediate purpose) and to enhance the excellence 
of the institution (underlying value) (Astin, 1991). An immediate purpose in selecting 
students for admission into a particular educational program would occur when the grade 
point average (GPA) or admission test scores are used as criteria. Colleges are interested 
in admitting those students with the best possible GPAs and highest possible test scores. 
Admission of these students suggests academic excellence and higher quality academic 
program, which encompasses an underlying value of the institution.  
Classroom assessment is another activity in connection with college courses. 
Compilation of course grades are used to generate each student?s GPA. Uses of the GPA 
vary and may be used for determining eligibility for graduation, honors, probation, or for 
selecting and screening students for admission or employment. Concerns about the GPA, 
according to Astin (1991), is that it does not fully represent what the student knows or 
their competencies. Instead, Astin stated the ?GPA is a relativistic or normative measure, 
i.e., how a student compares to other students at a particular time? (p. 12). Controversy 
exists over the extent of usefulness of the GPA (Pascarella & Terenzini, 1991; Scanlan & 
Care, 2004). 
Credentialing or certification is another use of assessment in relation to the 
college experience. In certain professions, such as medicine, law, accounting, and nursing 
tests are required for entry into practice or licensure (Astin, 1991). 
9 
  Results of the measurement provide information necessary for making decisions 
about the learning process. This decision making process incorporates making value 
judgments or an evaluation. The evaluation leads to decisions regarding which students to 
select for admission, progression, or graduation. Evaluation also is used when seeking 
alternative courses of action in pedagogical techniques (Oermann & Gaberson, 1998). 
Astin?s I-E-O model of assessment focuses on the college students? development 
using three elements: students? input assessments, the environment, and output 
assessments. The model has been used to study the impact of college attrition, success, or 
lack of success in education programs and student involvement (Pascarella & Terenzini, 
1991).  
The first of the three elements of the Astin (1991, 1993) model is input. Input 
refers to the personal qualities or characteristics of the student at the time of initial entry 
into the institution or to the education program. The input is significant for two reasons. 
The first reason is that it provides information about the students? strengths and 
weaknesses. The second reason is that it provides a baseline for assessing how much 
students actually learn and how much their performance improves between the beginning 
and end of a course. The input can provide an early opportunity to adjust teaching 
strategies during a particular course of study. Input measures are of two classifications: 
fixed characteristics and those that can change over time. Fixed type of data includes 
demographic data such as gender, age, ethnicity, income, and marital status. Cognitive 
functioning, aspirations, values, behavioral characteristics can change over time however, 
may be classified as input data. Sources of input data are admission and registration data, 
10 
results of placement tests, and any assessment during orientation or admission into an 
education program.  
Inputs can be identified as independent variables. Input data using the I-E-O 
model, can be used to show the effects of student interaction with the environment. 
Examples of this type of input data would be student gender, age, ethnicity, ability or 
socio-economic level. Other institutional purposes of input data may be for admissions 
and recruitment, curriculum and program evaluation, and public information. 
The second element of the model is the environment. Assessment of the 
environment is the most challenging of the three elements. The broad basis of the 
environment includes any occurrence that happens to the student during the educational 
program that might influence the outcomes under consideration. Factors included in the 
environment include the curriculum; pedagogical techniques; facilities; behavior of 
classmates and friends; co-curricular activities; and special programs such as orientation, 
remediation, or honors. .  
In assessing the environment, Astin (1991) discusses three issues: unit of 
observation, self-produced environment, and source of the data. The unit of observation 
is the entity to which the measurement is being applied. The entity may be the student, 
the faculty member, or the institution depending on the rationale for the study. A second 
issue is the student?s self-produced environment where the student chooses their own 
living or study environment. Sources of environmental data include institutional records 
and student surveys.  
The third element of the I-E-O model is outcomes. Outcomes are resulting 
characteristics educators are attempting to incorporate in an education program or 
11 
develop after exposure to the environment (Astin, 1991, 1993). The outcomes reflect the 
aims and objectives of the educational program.  
Outcomes may be cognitive or affective. Cognitive outcomes comprise 
knowledge and higher order mental processes including specific subject matter 
knowledge, academic ability, academic achievement, and professional competency. 
Affective outcomes are feelings, attitudes, and values that may be measured using self-
administered questionnaires. Outcomes may be short-term measures such as GPA, receipt 
of honors, or long term measures that include successful completion of an educational 
program or subsequent job performance. Outcomes are oftentimes dependent variables 
such as posttests, standardized tests results, measurements of retention, end of program 
assessments, or GPA (Astin, 1991).  
 Astin?s (1991) I-E-O model was used as a guide for this study. The elements of 
the I-E-O model and the relationships in this study were: 
a.  The GPA used for admission into the program and the HESI Admission 
Assessment (HESI A2) are addressed as input in the model. 
b.  The environment in the study is one southern public university 
baccalaureate in nursing program.  
c.  The output includes the completion of the nursing courses in the junior 
year of the nursing education courses. 
 
Limitations of the Study 
 Several limitations to the study are identified. The first limitation was that the data 
were archival from one baccalaureate nursing education program at a southern university. 
12 
A convenience sample over a three-year time frame was used. A convenience sample is 
the weakest form of sampling and has the greatest risk of sampling bias (Polit & Beck, 
2004). Retrospective data prevents manipulation of any intervening variables. Intervening 
variables that could occur between administration of the HESI A2 and completion of the 
first year nursing courses were not identified or studied. 
 
Assumptions 
For the purposes of this study, several assumptions were identified. Early 
identification of students who will not be successful in a nursing education program is 
more beneficial than waiting until the culminating nursing course. Faculty can provide 
remedial interventions for those students identified early in the education process as 
being potentially unsuccessful. Attrition in nursing education programs is expensive to 
the student, faculty, and administration. Another assumption related to the participants 
was that the participants were representative of future applicants of the nursing education 
program. An assumption was made that the students taking the HESI A
2
 were motivated 
to exert their best effort in selecting their answers. 
 
Definition of Terms 
The following terms are defined for interpretation of their use in this study: 
Admission GPA is the average score calculated from grades received in academic 
pre-requisite courses taken prior to admission into the nursing education program. Pre-
requisite courses include English composition and literature, fine arts elective, history, 
government, sociology, general psychology, finite math, biology, introduction to 
13 
chemistry, nutrition, anatomy and physiology I, anatomy and physiology II, 
microbiology, and developmental psychology. The university is on a four-point scale. 
Grades in the pre-requisite courses that are below a C are not accepted and must be 
repeated. 
Baccalaureate Nursing Education Program (BSN) is an organized program of 
study leading to the baccalaureate degree in nursing which requires at least 120 semester 
credit hours in pre-requisite academic support courses and major nursing theory and 
concurrent clinical courses.  
Grade Point Average (GPA) is the calculated average score based on grades 
received from courses taken in the academic setting.  
Health Education Systems, Inc. Admission Assessment Examination
TM 
(HESI A
2
) 
is a measurement instrument designed to assist faculty in pre-nursing selection and 
placement decisions and is given to students prior to admission into the nursing education 
program.  
HESI A
2
 based factors includes scores in the following components of the 
examination: Math, Reading Comprehension, Grammar, Vocabulary, Anatomy and 
Physiology, Chemistry and Behavioral Inventory. Also included is the learning style and 
personality profile portion of the examination. 
National Council Licensure Examination for Registered Nurses (NCLEX-RN) is 
the national computerized adaptive examination developed to measure the competencies 
of an entry-level registered nurse necessary to practice safe, effective care. State licensure 
is based on passing this examination. 
14 
Nursing Education Program is a program of study whereby a student upon 
successful completion will possess an associate degree (two-year), diploma (three-year), 
or baccalaureate degree (four-year) in nursing and is eligible to apply for nursing 
licensure in the United States or its territories. 
Success in the junior year is defined as completing the following nursing theory 
courses with a grade of C or better: NURS 3410 (Pathophysiology), NURS 3510 
(Nursing Skills), NURS 3610 (Holistic Assessment), NURS 3710 (Professional Nursing 
Concepts I), NURS 3320 (Pharmacology), NURS 3420 (Nursing Research and Data 
Management) NURS 3720 (Holistic Nursing: Adults and Geriatrics), and NURS 3740 
(Holistic Nursing: Infants and Children). 
Upper division of the nursing education program is defined as the nursing theory 
and concurrent clinical courses taken during the junior and senior academic year.  
 
Organization of the Study 
This study is divided into five chapters. Chapter I introduces the study; identifies 
the problem, purpose, research questions, and significance of the study; describes the 
theoretical framework; identifies limitations and assumptions; and defines the significant 
terms of the study. Chapter II includes a review of literature that focuses on the history of 
baccalaureate nursing education, and essential functions and attributes required for 
nursing practice and integral to nursing education. The magnitude of the current shortage 
of practicing nurses and nursing education faculty will be discussed. Concepts of 
assessment, measurement and evaluation used in nursing education are included. 
Prediction is defined and published studies of predictors of success in nursing education 
15 
are identified. Methods for the study are presented in Chapter III including the 
participants and sample, variables of interest, measurements, data collection and methods 
used for data analysis. Chapter IV reports the findings of the study. Chapter V concludes 
with a summary of the study, conclusions, implications and recommendations for further 
research and for nursing program educators. 
 
 16
 
 
 
 
 
 
 
 
 
II. REVIEW OF LITERATURE 
 
Introduction 
 Today?s baccalaureate nursing education programs provide demanding theoretical 
and clinical experiences to prepare the nurse graduate to practice in a challenging and 
perpetually changing workplace. Nursing students are required to maintain the rigors of 
the curriculum and successfully complete each sequential nursing course. Nursing faculty 
are confronted with the challenge to maintain the integrity of the program and prepare the 
student following graduation for passing the NCLEX-RN and providing safe, effective 
nursing care to the public.  
A current nursing shortage exists which effects practicing nurses and nursing 
faculty in education programs. Publicity about the current nursing shortage and 
sponsorships of nursing education such as Johnson & Johnson?s Campaign for Nursing?s 
Future (AACN, 2004; AACN, 2005; Johnson & Johnson, 2005) and the Nurse 
Reinvestment Act (2002) has created a surge of students seeking application to nursing 
programs. The influx of nursing student applications along with a shortage of nursing 
faculty has caused nursing education programs to turn away qualified applicants (Berlin, 
Bednash, & Stennett, 2001; Berlin, Stennett, & Bednash, 2003; Berlin, Stennett, & 
Bednash, 2004; Berlin, Wilsey, & Bednash, 2005; Hinshaw, 2001; National League for 
Nursing [NLN], 2005). Establishing criteria for the selection of those applicants who will 
 17
be admitted into the nursing program is a difficult yet necessary role for faculty and 
nursing program admission committees.  
Studies in the nursing literature have attempted to identify criteria that could be 
used for admission selection. However, most of these studies focused on the prediction of 
success or failure on the NCLEX-RN (Alexander & Brophy, 1997; Arathuzik & Aber, 
1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; Brisco & Anema, 1999; 
Campbell & Dickson, 1996; Crow, Handley, Morrison, & Shelton, 2004; Daley, 
Kirkpatrick, Frazier, Chung, & Moser, 2003; Haas, Nugent, & Rule, 2004; Nibert & 
Young, 2001; Nibert, Young, & Adamson, 2002; Sayles, Shelton, & Powell, 2003; 
Schmidt, 2000; Seldomridge & DiBartolo 2004; Washington & Perkel, 2001). The 
NCLEX-RN is taken following graduation from a nursing education program. By this 
time, attrition has occurred and some students have either been academically 
unsuccessful in the nursing courses or have withdrawn from the program due to personal 
reasons. Student attrition leaves unfilled cohort positions that could have been filled by 
other qualified students. If these potentially unsuccessful students had been identified 
earlier, perhaps remediation could have prevented the exodus from the nursing education 
program or more qualified students could have been selected. Earlier identification of 
those students who might have been academically successful or unsuccessful needs to 
occur. 
The purpose of this study was to examine if a pre-assessment nursing review 
could identify or predict which students would have been successful in the first year of 
the nursing education program at one public baccalaureate nursing program in the 
southeastern region of the United States. The GPA calculated from the pre-requisite 
 18
academic support courses for nursing and the results from the Health Education System, 
Inc. Admission Assessment (HESI A
2
) examination were two selected variables used to 
predict success in the first year in the nursing program. Success is determined by 
completing the junior nursing courses with a C or better. Criteria that can be used for 
admission selection or the identification of potentially successful or unsuccessful students 
early in the nursing program will assist nurse educators in directing those students. 
The review of literature for this study will provide an understanding of nursing 
education and practice. The review begins by focusing on the history of baccalaureate 
nursing education. The core competencies required for the practice of nursing will be 
identified in addition to how baccalaureate nursing education programs focus to prepare 
graduates to possess those competencies. The magnitude of the nursing shortage and its 
effect on nursing education will be discussed. The review also elaborates on the role of 
assessment, measurement, and evaluation in nursing education. Finally, a discussion of 
prediction and predicting success in nursing education programs is addressed. 
 
History of Baccalaureate Nursing Education 
Florence Nightingale?s desire to help the infirm of the British army in the 
Crimean War around 1856 established a pattern of behaviors known as the modern 
secular profession of nursing (Reverby, 1984). Her desire to eliminate the deplorable 
conditions of the hospital treating the British army soldiers became a reality with her 
leadership ability. Her efforts succeeded in overcoming longstanding prejudices about 
nursing from physicians and the public and led to an elevation in the status of all nurses. 
 19
Dolan (1963) recognized Nightingale as raising the status of nursing, improving the 
quality of nursing care, and as the founder of modern nursing education. 
Following international recognition for her courage and perseverance in changing 
the conditions at the military hospital, Nightingale pursued two goals: reform of army 
sanitary practices and the establishment of a school for nurses (Kalisch & Kalisch, 2004). 
Using the practices she began with the British military hospital, she originated a nurse 
training school as an experiment at St. Thomas? Hospital in London in 1860, which later 
served as the basic foundation for the education of nurses in the United States (Chitty, 
2005). Most of the physicians in London at this time opposed the project. It was 
considered that nurses needed little training because their roles were similar to house 
maids.  
Nightingale desired to share her thoughts on the caring for the health of others. 
She published her Notes on Nursing: What It Is, and What It Is Not which for decades 
served as the standard text for nursing practice. In her notes, Nightingale (1859) wrote 
that the most essential part of nurses? training was: 
? to teach them what to observe?how to observe?what symptoms indicate 
improvement?what the reverse?which are of importance?which are of none?
which are the evidence of neglect?and of what kind of neglect. (p. 59) 
This observation, Nightingale believes, is for the sake of saving life and increasing health 
and comfort.  
She further stipulated that nurses must use one?s own senses to make impressions 
of the patient. This ability, according to Nightingale, is essential to nursing. In her 
writings, she also warned against non-trained personnel (Kalisch & Kalisch, 2004).  
 20
During the Civil War, conditions in United States? military hospitals were similar 
to those found in the British military hospital during the Crimean War (Chitty, 2005). In 
America, there were similar prejudices regarding the inappropriateness of a woman 
taking on the roles of a nurse especially in military hospitals since it was a male 
dominated society (Kalisch & Kalisch, 2004). Nightingale?s influence crossed the ocean 
to the United States. 
  In 1862, Dr. Marie Zakrzewska opened the New England Hospital for Women 
and Children in Boston with the expressly stated purpose for the training of nurses. This 
program included six months of training in the practice of maternity and childcare 
(Kalisch & Kalisch, 2004). The program was expanded ten years later into the first 
general training school for nurses under the auspices of female physician-instructors. The 
training program located in the hospital offered lectures on medical, surgical and 
obstetric nursing. Students in the program, or trainees as they were called, resided at the 
hospital. Apprenticeships, which were the accepted method of instruction for the 
practicing of nursing skills, comprised 98 to 99% of the program teaching methods 
(Reverby, 1984). 
Modeling after the Nightingale system, several other training schools began 
operation in New England in the late 1800s (Chitty, 2005). At times, applications for 
admission were exceedingly high until the trainees realized the amount of time and effort 
necessary for completion of the program. Strict rules placed on the student nurses and 
women?s role in society often dictated the number of applications and admissions. 
Curricular theory content included anatomy and physiology, surgical and medical 
emergencies, obstetric and gynecological nursing, nursing of children, nervous diseases, 
 21
dietetics, hygiene and materia medica currently known as pharmacology. Lectures were 
provided by male physicians (Kalisch & Kalisch, 2004). 
By 1900, there were 1006 nurse training schools in the United States. Admission 
criteria included two years of high school and home education with knowledge of 
housekeeping duties. Nursing theory, ethics, bacteriology, and massage were added to the 
now three-year program of training. While physicians taught the core medical and 
surgical content, registered nurses were beginning to teach as well. Practical training was 
under the supervision of registered nurses and continued to consist of long strenuous 
hours (Kalisch & Kalisch, 2004). 
World War I demanded a greater number of nurses appropriately educated. In 
1918, Vassar College experimented with a training program to demonstrate that college 
graduates and those with a longer period of academic education would be a special asset 
in the training of nurses. A 3-month preparatory course added pre-nursing courses in 
chemistry, economics, history, and psychology to the curriculum. The program, which 
sent students to cooperating hospitals for the remainder of the program, was successful 
and spread to five universities throughout the United States. The program showed how 
cooperating higher educational institutions could include training of nurses. The standard 
of teaching was higher at the university than most nursing schools (Kalisch & Kalisch, 
2004).  
Another arrangement for nurse training in university settings occurred between 
the years of 1916?1920. A combination of academic and professional courses for four to 
five years led to a diploma in nursing and bachelor?s degree in nursing or science. 
Following high school, preliminary course work was completed at the university 
 22
followed by two years of nursing training at the hospital with a year of clinical 
specialization (Kalisch & Kalisch, 2004; Reverby, 1984). The numbers of interested 
students and results of this type of training were disappointing. The hospital continued to 
be dependent on the students for patient care and the course of study was long and 
tedious (Kalisch & Kalisch, 2004). 
Yale University received a grant from the Rockefeller Foundation in 1924 to 
initiate a nursing program as a separate department with its own budget and dean. The 
stipulation was to establish the shortest feasible curriculum, which consolidated nursing 
theory and practice into a curative and preventive framework. Pre-nursing courses 
included chemistry, psychology and biologic sciences. This program led to a Bachelor of 
Nursing degree and included public health, community work and hospital service. The 
program was deemed successful by the Rockefeller Foundation. The success of the 
program promoted ?attainment of a high degree of technical skill and an understanding of 
the underlying principles? (Kalisch & Kalisch, 2004, p. 230) with an insight into the 
social and economic forces that affect the patient. 
The movement to the university setting continued to be plagued with financial 
difficulties and opposition from physicians and university administration. The physicians 
fostered the belief that nurses were over-trained and that brief training in bedside routines 
would be sufficient. Laws for the registration of nurses did not mandate the higher 
standards for nursing education. Additionally, standards for curricula in nursing 
education programs were non-existent. Practical experiences for nursing students were 
limited to the type of hospital in which the education program was located. The education 
program was a working department where the students were responsible for furnishing its 
 23
nursing service as apprentices (Kalisch & Kalisch, 2004). Administrations of universities 
were reluctant to accept nursing as a discipline in academics (Chitty, 2005). 
In the late 1920s, most nursing education continued to be at an apprenticeship 
level in the hospital issuing a diploma upon graduation. Hospitals exploited student 
nurses in an attempt to save money in caring for the patients (Kalisch & Kalisch, 2004) 
and to staff the hospitals (Chitty, 2005). Financial burdens and difficulty in locating 
faculty with scholastic qualifications created an additional deficiency in nursing 
education and graduations of nurses for the workforce (Kalisch & Kalisch, 2004). 
A shortage of nurses continued throughout World War II. In 1952, nursing 
education programs proliferated in community and junior colleges. The purpose of this 
movement was to prepare bedside nurses for beginning general-duty positions at a faster 
rate to help reduce the critical shortage of nurses. This plan would add some academic 
experiences to nursing education thus offering a two-year associate degree in nursing. 
The three-year hospital diploma programs began having financial difficulty maintaining 
enrollments (Kalisch & Kalisch, 2004). 
In the 1950s, baccalaureate nursing programs were seen as standard diploma 
programs offered in a collegiate setting. The quality of the baccalaureate graduate could 
not be differentiated from the diploma graduate. In 1957, a paper published by the 
National League for Nursing (NLN) described the need for increasing the number of 
baccalaureate nursing graduates in preparation for graduate study for teaching, 
administration, and supervision (Kalisch & Kalisch, 2004). Universities needed to 
provide educational resources for the nursing programs at the same quality as other 
professional programs.  
 24
In addition, in the 1950s Margaret Bridgman from Skidmore College first referred 
to a separation of courses in baccalaureate nursing education programs (Keating, 2006). 
The lower division included general education courses and pre-requisite courses 
necessary for the support of the theory and practice of nursing. The lower division 
courses include physical, biological, and social sciences. The upper division courses were 
specific nursing theory and clinical practice courses, which included fundamental nursing 
skills and nursing skills for adults, children, mothers, and newborns.  
Funding for nursing education through the federal government by means of the 
Nurse Training Act of 1964 and Professional Nurse Traineeships assisted in the 
recruitment of nursing students and graduates in the 1960s (Kalisch & Kalisch, 2004). At 
this time, there were three levels of nursing education programs. The two-year associate 
degree in nursing, the three-year diploma of nursing, and the four-year baccalaureate 
degree in nursing existed. A lack of consistency in length of study and curriculum caused 
internal and public confusion of the profession of nursing. Employers of nurses had 
difficulty differentiating the levels of nursing graduates in practice (Nelson, 2002).  
In 1965, the American Nurses Association (ANA) proposed a position, whereby, 
nursing education would develop into two levels: technical and professional. This group 
recommended that in the future, all nursing education be based in colleges or universities. 
Students interested in technical nursing practice would consider junior or community 
colleges and earn an associate degree in a two-year program. Those students interested in 
professional nursing would attend four-year programs in a college or university setting. 
The basic preparation for entry level practice for a professional nurse would be the 
baccalaureate degree education in nursing (American Nurses Association Committee on 
 25
Nursing Education, 1965). This proposal by ANA sparked controversy from nursing 
educators and graduates from associate degree and diploma programs. This issue 
continues to be debated in nursing practice and education today. Additionally, the three 
levels of nursing education continue to exist today. 
 
Nursing Practice and Nursing Education 
Nursing practice focuses on health promotion, disease prevention, and 
management of client care in any type of setting. The knowledge and application of 
principles of growth and development, anatomy and physiology, disease 
pathophysiology, and the psychological and spiritual responses of the patient are 
imperative to being a safe, effective nurse. Baccalaureate education for nursing ensures a 
broad knowledge base and the ability to apply knowledge in making complex, critical 
decisions.  
National Council of State Boards of Nursing, Inc. (NCSBN, 1996) describes 
nursing practice as the implementation of strategies used to assist individuals or groups to 
attain or maintain optimal health by achieving defined goals and evaluating those 
responses to the care and treatment provided. More specifically, NCSBN (2003) in the 
NCLEX-RN Test Plan document defines nursing as:  
? both an art and a science, founded on a professional body of knowledge that 
integrates concepts from the liberal arts and the biological, physical, 
psychological and social sciences. It is a learned profession based on an 
understanding of the human condition across the life span and the relationships 
of an individual with others and within the environment. Nursing is a dynamic, 
 26
continually evolving discipline that employs critical thinking to integrate 
increasingly complex knowledge, skills, technologies and client care activities 
into nursing practice. The goal of nursing for client care in any setting is 
preventing illness; alleviating suffering; and protecting, promoting and restoring 
health. 
The registered nurse provides a unique, comprehensive assessment of the 
health status of the client (individual, family or group), and then develops and 
implements an explicit plan of care. The nurse assists clients in the promotion of 
health, in coping with health problems, in adapting to and/or recovering from the 
effects of disease or injury, and supporting the right to a dignified death. (p. 2) 
Caring for human beings in a vulnerable state as with illness or loss of a loved one 
requires a nurse to possess certain high-level specialized knowledge, skills, and abilities 
to succeed in carrying out the goal of nursing practice. Yocum (2003) reported on a 1996 
NCSBN study where categories of functional abilities necessary for the practice of 
registered nurses were identified. These categories represent mostly higher cognitive 
functioning and psychosocial skills. Among these categories were the ability for reading, 
competence in arithmetic skills, emotional stability, analytical thinking, critical thinking, 
interpersonal skills and communication skills.  
The American Association of Colleges of Nursing (AACN) published The 
Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998). 
The document articulates that professional nursing requires ?critical thinking, 
communication, assessment skills, and a balance of intelligence, confidence, 
understanding and compassion ?? (p. 6) in order to fulfill the diverse roles of nursing 
 27
practice. The domain of nursing practice is derived from knowledge of a variety of other 
fields and disciplines such as chemistry, mathematics, and social and behavioral sciences. 
Benner (1984) reiterates the basis for safe nursing care and the discretionary judgment 
needed for providing safe care comes from a strong educational background in biological 
and psychosocial sciences and in nursing arts and sciences.   
Critical thinking, identified by both NCSBN and AACN as a major component of 
nursing practice, involves decision making (Keating, 2006). Critical thinking is a process, 
which involves making a judgment based on cognition and taking a planned action. 
Critical thinking, as in nursing practice, requires the application of conceptual 
knowledge, the ability to analyze the situation and to evaluate different perspectives and 
formulate a final activity (Anderson & Krathwohl, 2001). Brookfield (2004) describes 
critical thinking as a process of recognizing and researching one?s beliefs that support 
their thoughts and actions. 
The development of the competencies required for nursing practice begins in the 
nursing education program. Nursing educators have the monumental task to prepare 
graduates for the skills and roles in the practice of nursing.  In baccalaureate nursing 
education programs, AACN (1998) depicts several components essential for preparing 
baccalaureate students to practice nursing. These components include liberal education, 
professional values, core nursing competencies, core nursing knowledge, and nursing role 
development. AACN describes liberal education as providing a knowledge base in the 
arts, sciences and humanities, which promotes analytical and critical thinking and is the 
basis for clinical nursing judgment. Liberal education enables students to assimilate 
different perspectives and experiences when making choices for patient care and to 
 28
communicate effectively orally and in writing. Iwasiw, Goldenberg, and Andrusyszyn 
(2005) identified psychosocial and health science courses as: 
? integral to the development of open-minded, educated and informed 
practitioners. Students? interaction with an array of concepts, processes, and 
world-views expands the depth and scope of their learning, and helps them to 
think critically from a broader, more comprehensive knowledge base. (p. 182) 
Pre-requisite academic courses in the arts, sciences, and humanities are required early in 
the curriculum or may be integrated strategically with the nursing courses (Boland & 
Finke, 2005).  
Core competencies of nursing according to AACN (1998) include skills in critical 
thinking, communication, assessment, and basic technical skills. In a nursing education 
program, the competencies are applied through clinical laboratory experiences under the 
auspices of a faculty member to the care of patients in a variety of settings including the 
community health care facilities or primary care settings, hospitals or acute care settings, 
and in the home. Students learn how to care for adults and children with medical, 
surgical, and mental health needs. Additionally, care of the maternity patient and 
newborn is taught. Students in baccalaureate nursing programs learn skills essential for 
nursing practice with the scientific basis of the application of the skills. 
Teaching nursing theory and skills necessary for the care of patients in the health 
care settings is a role of the faculty in the nursing education programs. Nursing educators 
facilitate learning by creating a positive learning environment (DeYoung, 2003). 
Educators provide cognitive, psychomotor, and affective learning activities in a simple to 
 29
complex sequence to assist the learner to integrate concepts and recognize relationships 
in nursing theory and skills (Jeffries & Norton, 2005).  
Furthermore, nursing educators provide a variety of learning activities to meet the 
different learning and information processing styles, which maximizes learning potential 
(Dunn, 1998; Dunn & Griggs, 2000; James & Maher, 2004, Linares, 1999). Dunn (1998) 
provides examples of learning activities for different learning and processing styles. 
Lecture, case study discussions in groups, and audiotapes can assist auditory learners. 
Charts, videos, computer discs are best for visual learners. Role-playing, games, and 
experimental activities are provided for kinesthetic learners. Analytical processing 
learners prefer a sequential explanation of the concept or topic with a checklist or outline. 
Global processing learners relate holistically to the concept by understanding the concept 
or topic before concentrating on the details. Providing an overview of the concept 
followed by details assist the global learner to process the information. Exposing nursing 
students to a variety of learning styles can assist the student to become adaptive to the 
complex conditions in the work environment (Colucciello, 1999; Rakoczy & Money, 
1995).  
 A typical baccalaureate nursing education curriculum consists of eight to nine 
semesters beginning with pre-requisite arts and sciences courses followed by nursing 
theory courses with concurrent nursing clinical courses. The junior and senior year 
courses usually are focused on the nursing sciences with emphasis on care of the patient 
in health care settings (Amos, 2005). The pre-requisite courses are chosen as necessary 
foundation courses for support of the nursing theory and clinical courses. Table 1 depicts 
 30
placement of pre-requisite courses and nursing theory and clinical courses similar to the 
Baccalaureate nursing education program used in this study.  
 
Table 1 
Typical Course Placement in a Baccalaureate Nursing Program by Semester 
Freshman I English Composition I 
Finite Math 
Biology with Lab 
Psychology 
Fine Arts 
Freshman II English Composition II 
Chemistry with Lab 
Anatomy and Physiology with Lab 
Sociology 
Fine Arts Elective 
Sophomore III Literature I 
Nutrition 
Anatomy and Physiology II with Lab 
History 
Ethics  
  
(table continues)
 31
Table 1 (continued) 
Sophomore IV Literature II 
Developmental Psychology 
Microbiology with Lab 
Political Science 
Junior  V Pathophysiology  
Nursing Skills and Lab 
Physical Assessment with Lab 
Professional Nursing Concepts I with Lab 
Junior VI Pharmacology 
Nursing Research and Data Management 
Nursing Care for Adults and Geriatrics and Lab 
Nursing Care for Infants and Children and Lab 
Junior or Senior VII Maternal and Newborn Nursing Care with Lab 
Community Mental Health Nursing Care With Lab 
Nursing Elective 
 (table continues)
 32
 
Table 1 (continued) 
Senior VIII Critical Care Nursing and Lab 
Leadership and Management in Nursing 
Community Health Nursing with Lab 
Senior IX Professional Nursing concepts II  
Preceptorship Practicum 
 
 
Many factors influence the practice of nursing and the education of nursing 
students. Historically, changes in society and the health care system influence nursing 
education curriculum (Keating, 2006). AACN (1998) discusses how changes in the 
complexity of the health care environment in today?s society, along with scientific 
advances, and the changing needs of a diverse population influence nursing practice and 
health care. New technological discoveries and innovations effect information 
management and clinical decision making in nursing. Additionally, the age, cultural, and 
lifestyle diversity of the population requires more critical thinking in order to apply 
nursing concepts to the care of those populations. This multiplicity of influences on the 
health care of individuals that requires nursing graduates from today?s nursing education 
programs to be able to master complex information, coordinate a complex system of care, 
and use technology for providing care delivery (AACN, 1998).  
 
 33
Nursing Shortage 
Buerhaus, Staiger, and Auerbach (2000) retrospectively analyzed the employment 
trends from the U.S. Bureau of the Census Current Population Surveys between 1973 and 
1998. The study determined that during the 1960s and 1970s students who entered the 
nursing profession were mostly female between the ages of fifteen to nineteen years. In 
the 1980s, the group of students increased with age whereby older students were entering 
nursing programs. Based on these documented trends, Buerhaus, et al. (2000) projected 
the future pattern of the nursing shortage to continue on the same path. By the year 2020, 
the size of the RN workforce will be approximately twenty percent below what is needed. 
Additional job opportunities for women and women choosing child rearing instead of 
employment added to the decrease number of nurses in the work force (AACN, 2003). 
Basically, the nursing shortage is a case of supply and demand (Shoichet, 2002). 
The factors contributing to the nursing shortage such as the aging workforce and 
job competition are identical to those affecting faculty positions. Hinshaw (2001) stated 
that the decrease in the number of faculty further adds to the nursing shortage because of 
limits placed on nursing enrollments. The current number of faculty is insufficient to 
meet the demands. Future replacements for the older generation of faculty are also 
lacking (Hinshaw, 2001). 
A shortage of registered nurses in the workforce is a complex societal concern 
due to various causes and issues. The Tri-Council for Nursing (NLN, 2004) comprised of 
the American Association of Colleges of Nursing (AACN), the American Nurses 
Association (ANA), the American Organization of Nurse Executives (AONE) and the 
National League for Nursing (NLN) issued a policy statement on the shortage. This 
 34
alliance of the four nursing organizations critically assessed the shortage by looking at 
the issue from the education, healthcare delivery system, and work environment 
perspective. The aging nursing work force in health care agencies and schools of nursing 
along with the decreasing numbers of nursing students enrolled and graduating negatively 
impacts the future of the shortage.  
Following the publicity and concern over the nursing shortage, nursing student 
applications to baccalaureate programs began to rise (Berlin, Bednash, & Stennett, 2001; 
Berlin, Stennett, & Bednash, 2003; Berlin, Stennett, & Bednash, 2004; Berlin, Wilsey, & 
Bednash, 2005). AACN annually surveys baccalaureate and graduate programs in nursing 
and reports the most current statistics on student enrollment and applications. Table 2 
depicts generic baccalaureate nursing student application data for a five year period, 
2000?2001 (Berlin, Bednash, & Stennett, 2001), 2002?2003 (Berlin, Stennett, & 
Bednash, 2003), 2003?2004 (Berlin, Stennett, & Bednash, 2004), and 2004?2005 (Berlin, 
Wilsey, & Bednash, 2005). The enrollment data for 2001?2002 (Berlin, Stennett, & 
Bednash, 2002) were reported without the application data. During this five-year time 
span, the number of applications received at baccalaureate nursing education programs 
steadily increased.  
 
 35
Table 2 
Enrollments, Applications Received and Accepted in Generic Baccalaureate Programs by 
Year 
Year Total Enrollment Completed 
Applications 
Received
Qualified 
Applications 
Accepted
 2000-2001
a
  72,986
   42,150 
 26,762
 2001-2002
b
  77,958
   NA 
  NA
 2002-2003
c
  85,415
   54,194 
  35,542
 2003-2004
d
  95,766
   86,671 
  43,721
 2004-2005
e
  112,180
   122,194 
  54,577
Total   444,305
   305,209 
160,602
a
Berlin, Bednash, & Stennett, 2001; 
b
Berlin, Stennett, & Bednash, 2002; 
c
Berlin, 
Stennett, & Bednash, 2003; 
4
Berlin, Stennett, & Bednash, 2004; 
5
Berlin, Wilsey, & 
Bednash, 2005 
 
The increase in applications identified in the findings from AACN surveys poses 
a dilemma to the administration of the nursing program. A lack of faculty and resources 
prohibits nursing programs from admitting all the potential students (Berlin, Bednash, & 
Stennett, 2001; Berlin, Stennett, & Bednash, 2003; Berlin, Stennett, & Bednash, 2004; 
Berlin, Wilsey, & Bednash, 2005), thus further adding to the nursing shortage. Table 2 
also shows that generic baccalaureate nursing programs received a total of 305,209 
completed applications, even without the 2001?2002 data. The nursing program faculty 
 36
has to identify and select those students who will be most successful in the nursing 
program and this decision may not be an easy one. Admission criteria must be established 
to identify those students who will be most successful (Astin, 1991). From this data, fifty-
three percent of the applications were accepted.  
The National League for Nursing (NLN) further documents the significant 
increase in qualified applicants not accepted into nursing education programs (NLN, 
2005). The NLN?s 2005 National Nursing Education Database Survey of all nursing 
education programs in the United States and its territories reported that an estimated 
147,465 qualified applications were rejected by nursing programs in 2004?2005.  
 
Assessment, Measurement, and Evaluation in Nursing Education 
Nursing education programs investigate various means of assessment to assist in 
decision making. Assessment, according to Astin (1991), refers to two different activities: 
the collecting of information termed measurement and the use of that information for 
institutional and individual improvement or for evaluation. Linn and Gronlund (2000) use 
the term assessment to include a wide range of quantitative methods of obtaining 
information or measurements about students and the formation of value judgments 
concerning the progress of learning.  
Assessment of students occurs throughout the college experience. Assessment has 
two purposes. The immediate purpose is to help select students for admission. The 
second purpose is to augment the underlying value such as to enhance the excellence of 
the institution (Astin, 1991). Assessment involves the collection of data over time 
(Oermann & Gaberson, 1998). Astin (1991) suggests that an immediate purpose in 
 37
selecting students for admission into a particular education program would occur when 
the GPA or admission test scores are used as criteria. Higher education institutions are 
interested in admitting those students with the best possible GPAs and highest possible 
test scores. Admission of these students suggests academic excellence and higher quality 
academic program, which encompasses an underlying value of the institution (Astin, 
1991). 
The term ?measurement? is the process of assigning numbers to represent student 
achievement according to certain rules or a reference point (Linn & Gronlund, 2000; 
Oermann & Gaberson, 1998). Tests are one form of measurement and test scores are 
usually represented by a number. However, Oermann and Gaberson (1998), surmise that 
meaning must be applied to the number so that the score can be interpreted.  
Three factors are important when interpreting test scores: reliability, validity and 
absence of bias (Woolfolk, 2004). Reliability refers to the stability, internal consistency 
or precision of the results of a test and is statistically measured by means of a correlation 
coefficient (Linn & Gronland, 2000). To improve the reliability of a test, Woolfolk 
(2004) suggests adding more test items to the test. The validity of a test includes the 
appropriateness of the interpretation of the results and is specific to the individual 
purpose of the instrument (Linn & Gronland, 2000; Woolfolk, 2004).  
Validity is the degree to which the instrument measures what it is designed to 
measure (Wiersma, 2000). The types of validity are based on the evidence used for 
establishing the validity. Wiersma (2000) depicts the different types of evidence as 
related to content, concurrent criterion, predictive criterion and construct. Criterion and 
 38
construct validity can be measured through empirical analysis. Content and, to an extent, 
construct validity can be analyzed logically. 
Classroom assessment is another activity connected with college courses. 
Outcomes from course requirements are measured in grades for the course. A 
compilation of course grades generate into the GPA for each student. Uses of the GPA 
vary. They may be used for determining eligibility for graduation, honors or probation or 
for selecting and screening students for admission or employment. There are concerns 
about the GPA because it tells very little about what the student knows or their 
competencies (Astin, 1991). Instead, Astin reiterates the GPA is a relativistic or 
normative measure, which is used to show how a student compares to other students at a 
specific point in time. In contrast, Pascarella and Terenzini (1991) stated that a student?s 
grades are the most revealing indicator of his or her successful adjustment to the 
intellectual demands of a particular course of study.  
Nursing course grades determine success or failure in the nursing program. 
Established school of nursing policies dictate the criteria for student progression into the 
next nursing course or level. Policies may identify individual nursing course grades or 
overall nursing course GPA as a criterion for attrition (Jeffreys, 2004). Nursing programs 
are prone to high attrition rates because of the demanding curriculum of a nursing 
education program. Students who fail a nursing course or withdraw from a nursing course 
are at risk for attrition from the nursing education program. Jeffreys emphasizes that 
progression policies further add to the risk for attrition. 
Caution is advised about grades because of personal influences such as 
motivation, study habits, and effort (Pascarella & Terenzini, 1991). Scanlan and Care 
 39
(2004) further add external factors such as rising consumerism, faculty?s concern over 
promotion and tenure decisions, and institutional policies to the list of effects on grades. 
Credentialing or certification is another use of assessment. In certain professions, 
such as medicine, law, accounting, and nursing, tests are required for entry into practice 
or licensure (Astin, 1991). For nursing licensure, the NCLEX-RN is a computer adaptive 
test developed by the National Council of State Boards of Nursing, Inc. designed to 
measure the competencies necessary to practice safe, effective nursing care. The 
examination assesses the knowledge, skills, and abilities that are essential to the safe, 
effective practice of professional nursing at the entry level (NCSBN, 2005). The test plan 
of the NCLEX-RN examination incorporates client needs across the lifespan and in 
various clinical settings. The test plan categories for the registered nurse examination 
include client needs according to the following areas: safe, effective care environment, 
health promotion and maintenance, psychological integrity, and physiological integrity 
(NCSBN, 2003). Nursing process, caring, communication, and teaching/learning are 
essential concepts of nursing that are integrated throughout the examination. The majority 
of the test items are written at application level or above of Bloom?s Taxonomy for the 
cognitive domain (Anderson & Krathwohl, 2001; Bloom, 1956). The application level or 
higher ?requires more complex thought processing? (NCSBN, 2003, p. 3). The NCLEX-
RN was developed using criteria established after the completion of a job analysis of 
entry-level registered nurses (Chornick & Wendt, 1997). 
Evaluation according to Astin (1991) is the rendering of value judgments. 
Measurement alone does not imply value judgments. Results of the measurement provide 
information necessary for making decisions about the learning process. Evaluation of the 
 40
information generated by an assessment incorporates making a value judgment on the 
pedagogical methods or decisions for providing feedback to the student on the material.  
Evaluation is a complex and difficult process using professional judgment to 
interpret the information as a basis for decisions about the learner (Oermann & Gaberson, 
1998). The evaluation leads to decisions regarding which students to select for admission, 
progression or graduation. Evaluation is used when seeking alternative courses of action 
in pedagogical techniques and the overall program and curriculum.  
Information from measurements enables nursing faculty to make decisions about 
students concerning nursing education programs. According to Kubiszyn and Borich 
(2003), in addition to assessing content areas learned effectively and overall program 
evaluation, faculty use measurements to diagnose strengths and weaknesses of the 
student, and make decisions for the selection of applicants into nursing programs, and for 
counseling to recommend appropriate programs of study or remediation.    
In the nursing profession, results from the NCLEX-RN are used by state and 
territorial boards of nursing and nursing education program accrediting agencies to make 
decisions on licensure, continued approval of the nursing education program, or 
accreditation status of the nursing education program (NCSBN, 1999; NCSBN, 2003; 
NCSBN, 2004). Nursing graduates, deans, and faculty have an investment in the success 
on NCLEX-RN. Passing the NCLEX-RN means the graduate of the nursing education 
program is minimally competent to practice nursing (NCSBN, 2005). Results of the 
examination are sent to the state boards of nursing for a determination of licensure. 
Nursing graduates who do not pass this high stakes NCLEX-RN examination are not 
allowed to work as a registered nurse even if they have graduated from a nursing 
 41
program. National acceptance of the results by other state and territorial boards of nursing 
allows licensed registered nurses to apply for licensure in all states and territories 
(NCSBN, 2003; NCSBN, 2004).  
Board of nursing approval of the nursing education program allows the graduates 
to take the NCLEX-RN or apply for endorsement of the license into or from another state 
(Alabama Board of Nursing, n.d.; NCSBN, 2004). Nursing education program approval 
is contingent on the NCLEX-RN passing rate of the graduates. NCLEX-RN passing rates 
are reviewed by the board of nursing on a yearly basis. Some state boards of nursing 
withdraw approval of the nursing education program or place the program on probation if 
an established percentage pass rate for the graduates on the NCLEX-RN is not met 
(Alabama Board of Nursing, n.d.).  
Using the results of the NCLEX-RN for program approval or accreditation depicts 
the value or excellence of the institution. School of nursing and university accrediting 
agencies review pass rates as a criterion for continued accreditation (Commission on 
Collegiate Nursing Education [CCNE], 2003). Faculty members are cognizant of this 
outcome and identify their role in graduating successful nursing students. Programs that 
fail to maintain a specified passing rate may lose their approval or accreditation status. 
Faculties teaching in nursing programs have a vested interest in maintaining high passing 
rates and ensuring those who complete the program pass the licensure exam. 
 
Prediction of Academic Success 
One of the roles of faculty in nursing education programs is to determine criteria 
for the selection of students who will be accepted into the nursing program. Selection of 
 42
students is based on admission criteria or standards (Iwasiw, Goldenberg, & 
Andrusyszyn, 2005). With the faculty shortage and increased numbers of student 
applicants, not all students who apply will be selected. Identifying the potentially 
successful students presents a dilemma for faculty. The faculty desires to select students 
who will be successful in the rigorous nursing program and on the NCLEX-RN. Faculty 
must balance the rigors of the nursing program with sufficient applicants. If students are 
admitted to the program without adequate preparation, according to Engelmann (2004), 
the faculty must be willing to provide strategies to help the student achieve success. 
Establishing criteria by making predictions on academic achievement is one 
method to assist with the selection of an over abundance of applicants seeking admission 
into nursing education programs. Prediction, according to Wiersma (2000), is the 
?estimation of scores on one variable from information about one or more other 
variables? (p. 459). Prediction is the forecasting of how variables will perform in a new 
setting or with different individuals (Polit & Beck, 2004). Pedhazur (1997) identifies the 
use of predictive research for practical applications as having the goal to optimize the 
prediction of certain criteria. Prediction studies, according to Gay and Airasian (2003), 
facilitate decisions about individuals, aid in the selection process, to test variables 
believed to be good predictors, and to determine the predictability of measurements. 
Two types of variables are used in prediction. The predictor is the variable from 
which one predicts and the criterion variable, which is the variable being predicted 
(Wiersma, 2000). In some predictive research, the predictor and criterion variables may 
be interchangeable.  
 43
Admission decisions are based on solid empirical data. Perfetto (2002) identified 
four principles to guide the selection of objective predictors. The attribute must: (1) be 
reliable and reproducible, (2) be consistent for several consecutive classes, (3) 
demonstrate the ability to predict over the student?s undergraduate career, and (4) have 
academic relevance.  
The pursuit for predictive factors of academic performance has focused primarily 
on student characteristics, aptitude, and personality traits (Lavin, 1965). Most often, GPA 
is used as the quantitative method of expressing the student?s scholastic achievement. As 
discussed by Lavin, often the correlational relationships between such predictors and 
performance criteria are not very strong. He offers two reasons for these low correlations: 
(1) failure to isolate enough of the right variables and or measurement error in the 
variables and (2) uncontrolled sources of the variation in the grades.  
Lavin (1965) studied the prediction of academic performance using GPA. The 
precision of using grades to predict academic performance is difficult. The subjectivity of 
grades cannot be controlled. Grade inflation, which is the increase in grade point average 
without an associated increase in overall student ability, is prevalent in higher education 
although empirical data is lacking (Scanlan & Care, 2004). Scanlan and Care identified 
several reasons for grade inflation. One reasons for grade inflation is due to the use of 
collaborative pedagogical strategies that enables weaker students to achieve higher 
grades. Student pressure on faculty to give higher grades is a result of changing student 
demographics where there are more adult learners who are more mature and assertive in 
the classroom. Additionally, the faculty?s inexperience in evaluation of student learning 
leans more toward grade inflation. From a nursing education perspective, Scanlan and 
 44
Care add that the nursing shortage itself has urged faculty to graduate more students. The 
faculty shortage brings the use of teaching assistants and new inexperienced faculty into 
the classroom. Finally, the grading in the clinical nursing practice courses is subjective 
and possibly inflated by clinical faculty, preceptors, clinical associates, or teaching 
assistants. 
Lavin (1965) suggested the use of standardized tests as the index for academic 
performance to overcome the error associated with the use of grades. Uniform test scores 
as supplementary criteria of performance assists with the control of the subjectivity of 
grading.  
Determining predictors of success throughout the nursing education program has 
been a challenge for faculty. Campbell and Dickson (1996) completed a review of forty-
seven studies published between 1984 and 1990 on predictors of NCLEX-RN. The meta-
analysis showed the best predictors of graduation and NCLEX-RN success were nursing 
GPA, chemistry GPA, and American Achievement Scores (ACT) scores. The NLN pre-
nursing examination also showed the ability to predict success on NCLEX-RN. The least 
predictive variables were college cumulative GPA, liberal arts GPA, scores on the 
Scholastic Achievement Test (SAT), and examination scores in the nursing courses.
Predicting success on NCLEX-RN has been the subject of many recent studies in 
the nursing literature (Alexander & Brophy, 1997; Arathuzik & Aber, 1998; Barkley, 
Rhodes, & DuFour, 1998; Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; 
Brisco & Anema, 1999; Crow, Handley, Morrison, & Shelton, 2004; Daley, Kirkpatrick, 
Frazier, Chung, & Moser, 2003; Endres, 1997; Haas, Nugent, & Rule, 2004; Lauchner, 
Newman, & Britt, 1999; Newman, Britt, & Lauchner, 2000; Nibert & Young, 2001; 
 45
Nibert, Young, & Adamson, 2002; Nibert, Young & Britt, 2003; Sayles, Shelton, & 
Powell, 2003; Schmidt, 2000; Seldomridge & DiBartolo, 2004; Washington & Perkel, 
2001). Academic and non-academic variables have been studied as predictors of success 
on NCLEX-RN. Crow, Handley, Morrison, and Shelton (2004) completed a 
comprehensive survey of baccalaureate nursing education programs throughout the 
United States to identify what data were used to predict NCLEX-RN success. Ninety 
percent of the programs surveyed required a comprehensive examination that is given to 
the students during the later portion of the curriculum. Twenty-nine percent used a 
cumulative GPA of pre-nursing courses and nursing courses. Thirty-six percent of the 
programs reporting used specific nursing course grades to predict NCLEX-RN.  
The use of a standardized entrance examination and the SAT scores were the only 
reported admission criteria significantly correlated with passing NCLEX-RN. Although 
the specific standardized entrance examination was not described, Crow et al. (2004) 
identified one of the implications of this study as, ?BSN programs should consider using 
standardized entrance examinations as admission criteria to enhance the NCLEX success 
rates for their students and the program? (p. 183). 
Grade point average is an academic variable that has been studied to determine its 
predictability for success on NCLEX-RN (Brisco & Anema, 1999; Haas, Nugent, & 
Rule, 2004; Washington & Perkel, 2001). Grade point averages have been combined into 
three separate groups for analysis: GPA for pre-nursing courses only, GPA for nursing 
courses only, and cumulative GPA. Haas, et al. (2004) studied all three groups and 
determined the GPA of nursing courses only was found to be most predictive with 
baccalaureate students. Several studies compared the GPA from pre-nursing courses to 
 46
NCLEX-RN success but did not find a significant difference (Brisco & Anema, 1999; 
Haas, et. al, 2004; Washington & Perkel, 2001). Cumulative GPA from pre-nursing 
courses and nursing courses combined was determined to be a predictor in three studies 
(Beeson & Kissling, 2001; Daley, Kirkpatrick, Frazier, Chung, & Moser, 2003; Sayles, 
Shelton, & Powell, 2003). 
Pre-admission tests for nursing have been used in studies as potential predictors 
for passing NCLEX-RN (Sayles, Shelton, & Powell, 2003; Schmidt, 2000). These tests 
are administered early in the nursing education process and usually prior to admission 
into the program. Sayles, et al. (2003) studied the Nurse Entrance Test (NET) published 
by Educational Resources, Inc. (ERI) and identified that the NET composite score was 
statistically significant in predicting NCLEX-RN. Schmidt (2000) considered the 
National League for Nursing (NLN) Pre-Admissions Test as a predictor but did not find a 
significant correlation with NCLEX-RN. There are no published studies of the HESI A
2
 
as a predictor of NCLEX-RN since it is a recently developed instrument (Nibert, 2005).  
Barkley, Rhodes, and DuFour (1998) studied mid-curricular measurements to 
predict success on the NCLEX-RN. Mid-curricular tests are specialty content 
examinations such as those testing basic nursing knowledge for the care of children, 
adults, mental- health patients or maternal-newborn patients. These tests are given 
throughout the curriculum in conjunction with the specific nursing content course. 
Barkley, et al (1998) specifically studied the National League for Nursing (NLN) 
Achievement Tests as predictors for NCLEX-RN. The Psychiatric, Obstetrical, Adult 
Health, and Pediatric NLN tests showed a statistically significant correlation with 
NCLEX-RN. No studies have been published on the HESI Specialty Examinations. 
 47
Standardized comprehensive nursing achievement tests, which are administered 
immediately prior to graduation from the nursing program, have also been studied as a 
predictor of NCLEX-RN success. Recent studies have shown statistically significant 
correlations with passing NCLEX-RN. The Mosby Assess Test was found to be 
statistically significant for prediction of passing NCLEX-RN (Beeson & Kissling, 2001). 
Daley, Kirkpatrick, Frazier, Chung, and Moser (2003) did not find a relationship between 
NCLEX-RN and the Mosby Assess Test. Sayles, Shelton, and Powell (2003) determined 
that the PreRN Assessment published by Educational Resources Inc. was statistically 
significant in their study of associate degree nursing graduates. The Arnett Pre-RN 
Readiness Examination showed a significant relationship for prediction of the NCLEX-
RN in a baccalaureate nursing program (Washington & Perkel, 2001). The Diagnostic 
Readiness Test (DRT) by NLN was studied by Schmidt (2000) in all types of nursing 
education programs. The correlation of the DRT with the NCLEX-RN especially in the 
baccalaureate nursing programs was statistically significant. Seldomridge and DiBartolo 
(2004) studied the National League for Nursing Comprehensive Achievement Test for 
Baccalaureate Students and determined that it was a predictor of success and failure on 
NCLEX-RN. The HESI Exit Examination published by the developers of the HESI A
2
 
has been shown to be a statistically significant predictor of success on NCLEX-RN in a 
variety of nursing education programs (Lauchner, Newman, & Britt, 1999; Newman, 
Britt, & Lauchner, 2000; Nibert & Young, 2001; Nibert, Young, & Adamson, 2002; 
Nibert, Young & Britt, 2003). Daley et al. (2003) found that the scores on the HESI Exit 
Examination were significantly different in students who were successful in the NCLEX-
RN and those who were not. 
 48
Few studies have been published on early identification of those students who will 
be successful in the first year of nursing education programs (Gallagher, Bomba, & 
Crane, 2001; Lewis & Lewis, 2000; Potolsky, Cohen, & Saylor, 2003; Sandiford & 
Jackson, 2003). Gallagher et al. (2001) studied two pre-nursing examinations to 
determine if one examination was a better predictor of success in one nursing program. 
The Entrance Examination for Schools for Nursing (RNEE) published by The 
Psychological Corporation was compared to the Nurse Entrance Test (NET) published by 
Educational Resources, Inc. The NET was of interest because it provided scores on non-
academic areas such as stress levels and test taking skills. The two tests were compared to 
the course grade in the first nursing course and later to the course grade in the last nursing 
course. The RNEE was found to be the better predictor of the two examinations in the 
first nursing course and further analyzed using logistic regression. The reading 
comprehensive subtest score proved to be statistically significant (R = 0.23, p < 0.05) and 
determined to be useful for establishing a minimum score for entrance into the nursing 
education program. Neither examination proved to be a good predictor of success in the 
final nursing course. 
Lewis and Lewis (2000) studied the success of nursing students who transferred 
the pre-requisite support courses from other schools or universities. The dependent 
variable was academic success defined as the cumulative GPA of 2.5 or greater at the end 
of the junior year. Using logistic regression, the results showed that successful transfer 
students were more than twice as likely to transfer from 4-year institutions (odds ratio 
(OR) = 2.10, 95% confidence interval (CI): 1.10, 4.03) and more than five times as likely 
 49
have taken two or more anatomy and physiology courses (OR = 5.51, 95% CI: 2.76, 
11.02) than unsuccessful transfer students.  
Potolsky, Cohen, and Saylor (2003) studied the effects of tutoring services on the 
academic performance of first semester nursing students using the prerequisite science 
course grade and the nursing pathophysiology and pharmacology grades. Results showed 
a high correlation with the pathophysiology grade (r = .77, p = .01) and the 
pharmacology grade (r = .60, p = .01). There was not a control group in this study.  
Sandiford and Jackson (2003) studied the relationship of academic, 
socioeconomic, and motivational variables to attrition in the first semester of an associate 
degree nursing program. The results showed a statistically significant relationship with 
lower attrition rates and a score at college level in language on the Test of Adult Basic 
Education (p < .001) and a pre-semester GPA of 2.5 or above (p < .001). Three non-
academic variables, which included hours planned to work, financial difficulty, and 
achievement tendency were not significant. 
Types of statistical analyses used in studies for predicting success in nursing 
programs are documented into three categories: correlation coefficient (Barkley, Rhodes, 
& DuFour, 1998; Brisco & Anema, 1999; Sayles, Shelton, & Powell, 2003), logistic 
regression (Gallagher, Bomba, & Crane, 2001; Lewis & Lewis, 2000; Schmidt, 2000; 
Washington & Perkel, 2001), and discriminate analysis (Beeman & Waterhouse, 2001; 
Endres, 1997; Haas, Nugent, & Rule, 2004). Depending on the variables and reason for 
the study, logistic regression is more robust than discriminate analysis (Pedhazur, 1997).  
 
 50
Summary 
 Nursing has a long evolving history. In the 1850s, Florence Nightingale identified 
tasks, skills, and an environment necessary for the healing of individuals. As a female- 
dominated profession, the early years of nursing were masked with negative reactions 
from males and physicians. The perseverance of Nightingale and others led to the 
development of diploma, associate and baccalaureate degree nursing education programs. 
Nursing in the 21
st
 century requires core competencies that specify the knowledge, skills, 
and abilities needed to practice safe, effective nursing care in a variety of settings. The 
arduous demands of the nursing education program often prevents all selected students 
from being successful in the first year of the nursing curriculum. Attrition persists in 
undergraduate nursing education programs throughout the first year of nursing courses 
and up to graduation (Jefferys, 2004). Identification of those who are most likely to be 
successful early in the nursing education program is more beneficial to faculty and the 
students. Prediction of success in the nursing education program through assessment of 
the student early in the nursing education program or prior to admission into the program 
may help to recognize students who may encounter difficulty early in the program and 
allow nurse educators to identify strategies to help those students be successful or seek 
other careers. 
 
 51
 
 
 
 
 
 
 
 
 
III. METHODS 
 
Introduction 
The purpose of this study was to examine the relationship between the 
prerequisite academic support courses for a nursing program and the HESI A
2 
as a 
predictor of success in the first year of a baccalaureate nursing education program. This 
study also identified demographic characteristics, nursing theory course grades, and HESI 
A
2
 based factors that can be used to predict first year student success. This chapter will 
describe the participants of the study, the variables that were studied, the research design, 
sampling methods used, the instrument, procedures used for the study, and the type of 
analyses used. 
 
Research Questions 
Four research questions were addressed in the study: 
1. What is the relationship between the admission GPA and the HESI A
2
 for 
nursing students? 
2. What is the relationship between the admission GPA and success in the 
first year of the nursing education program?  
 52
3. What is the relationship between the HESI A
2
 scores and students who 
were successful in the first year of the nursing education program and those who were 
not?  
4. What demographic characteristics, nursing theory course grades, and 
HESI A
2
 based factors are predictive of success in the first year of the nursing education 
program?  
 
Participants 
 The target population for this study was drawn from nursing students applying for 
admission into the upper division of a baccalaureate nursing program at one public 
southeastern university. The participants included three cohorts of students seeking 
admission in the fall of 2001, 2002, and concluding with the fall 2003. Two hundred fifty 
eight applicants met the minimum requirements of 2.5 GPA and were sent letters of 
conditional acceptance for the nursing education program for the three years combined. 
One hundred seventy applicants were sent final acceptance letters. This number was 
partially based on the number of faculty and clinical site availability. One hundred sixty 
three applicants began the nursing program. 
 A total of 128 students met the criteria for inclusion in the sample. Included in the 
sample for this study were those students who completed the pre-requisite academic 
support courses with a 2.5 or higher, took the HESI A
2
 examination, were accepted into 
the upper division of the nursing program, and completed the junior nursing theory and 
clinical courses. Those who withdrew from the courses for academic or personal reasons 
prior to completion were removed from the sample.  
 53
 The participants were predominately female (91.4 %). The majority of the 
participants were Caucasian (79.7%). African Americans represented the largest number 
of ethnic minorities with 16.4%. Other ethnic groups represented were American Indian, 
Asian American, and Hispanic. The mean age of the students in the sample was 24.9 (SD 
= 6.23) with a range of 37 years. The range in years was from 20 to 57. 
The university chosen for the study was a public, state supported institution 
located on a 500-acre campus seven miles east of a major metropolitan area in the 
southeastern United States. Enrollment for undergraduate and graduate students is 
approximately 5100 per semester. The university offers undergraduate and graduate 
degrees through five schools: Liberal Arts, Sciences, Education, Nursing, and Business. 
The university is accredited by the Commission on Colleges of the Southern Association 
of Colleges and Schools to award the bachelor?s, master?s and specialist degrees. The 
academic year includes two 15-week semesters and one 10-week summer semester. The 
School of Nursing is approved by the state board of nursing and accredited by the 
Commission on Collegiate Nursing Education (CCNE).  
 
Variables of Interest 
 For the purposes of this research study, predictors of success are measured toward 
the dependent or criterion variable, which is success at the end of the junior year. Success 
at the end of the junior year includes a C or better in each of the nursing theory courses 
taught in the junior year. The nursing theory courses consist of NURS 3410 
(Pathophysiology), NURS 3510 (Nursing Skills), NURS 3610 (Holistic Assessment), 
NURS 3710 (Professional Nursing Concepts I), NURS 3320 (Pharmacology), NURS 
 54
3420 (Nursing Research and Data Management), NURS 3720 (Holistic Nursing: Adults 
and Geriatrics), and NURS 3740 (Holistic Nursing: Infants and Children). Co-requisite 
clinical components of the theory courses are taught and must be completed but are not 
included as variables in the study because of the pass or fail grading format. Holistic 
Pathophysiology, Nursing Skills, Holistic Assessment, and Professional Nursing 
Concepts I are taught in the fall semester of the junior year. Pharmacology, Nursing 
Research and Data Management, Holistic Nursing: Adult and Geriatric Populations, and 
Holistic Nursing: Infants and Children are taught in the spring semester of the junior 
year.  
The independent or predictor variables identified in this study included the 
admission GPA calculated from the pre-requisite academic support courses for nursing 
and scores from the HESI A
2
. Additional predictor variables recognized in this study 
included grades from selected nursing theory courses in the junior year, demographic 
characteristics of the participants, and selected HESI A
2
 based factors. 
 The curriculum of baccalaureate nursing education program used in the study 
required academic courses as pre-requisites to enter into the upper division of the nursing 
program. These pre-requisite academic support courses include English composition, 
English literature, a fine arts elective, history, government, sociology, general 
psychology, finite math, biology, introduction to chemistry, nutrition, anatomy and 
physiology I, anatomy and physiology II, microbiology, and developmental psychology. 
The grades from these pre-requisite courses were calculated as the admission GPA by 
dividing the total number of grade points for the pre-requisite courses by the total number 
of the credit hours of the pre-requisite courses. The GPA was used as a criterion for 
 55
acceptance into the upper division of the nursing education program. The upper division 
includes the nursing theory and clinical courses of the junior and senior year. A student 
must have at least a 2.5 GPA based on a 4.0 scale of the pre-requisite academic support 
courses in order to apply to the upper division. 
 The scores from the HESI A
2
 comprised another set of independent variables. The 
HESI A
2
 was administered at the School of Nursing via computer under proctored, timed 
conditions as dictated by Health Education System, Inc. protocol. The HESI A
2
 was 
administered after completion of all the pre-requisite courses and prior to beginning the 
first nursing theory course. The components of the HESI A
2
 used in this study include 
mathematics, reading comprehension, vocabulary, grammar, chemistry, and anatomy and 
physiology. A cumulative score from the HESI A
2
 includes scores in the above areas. 
Part of the HESI A
2
 included a profile of the student?s learning style, personality profile, 
and behavioral inventory and also was analyzed as independent variables. 
 The junior year nursing theory course grades comprise another group of 
independent variables. In the fall semester, the students enroll in Pathophysiology, 
Nursing Skills, Holistic Assessment, and Professional Nursing Concepts I. Holistic 
Pathophysiology is a three-hour credit course, which explores the holistic view of 
pathophysiology and psychoneuroimmunology. Nursing Skills is a one-hour credit course 
with a separate three hour per week clinical lab component where the theory for the safe 
practice of nursing skills including sterile technique, medication administration, and 
assisting with activities of daily living is taught. Holistic Assessment is a three-hour 
credit course with a six hour per week separate clinical component. Holistic Assessment 
incorporates concepts and theories of nursing process with an emphasis on performing a 
 56
head-to-toe physical assessment. Professional Nursing Concepts I is a two credit hour 
course with a three hour per week separate clinical lab component. This course teaches 
foundation concepts and roles for professional nursing practice.  
The grades for the nursing courses taught in the spring semester of the junior year 
and used in the study include Pharmacology, Holistic Nursing: Adults and Geriatrics, and 
Holistic Nursing: Infants and Children. Pharmacology is a two-hour credit theory course 
incorporating the principles of pharmacology in professional nursing practice. Holistic 
Nursing: Adult and Geriatric Populations involves learning and applying the concepts 
and theory of nursing practice specific to adults and geriatrics patients in a three hour 
credit course and a separate six hour per week clinical lab component. Holistic Nursing: 
Infants and Children course includes a two-hour credit theory course containing the 
application of concepts and theories of professional nursing practice in the care of infant 
and children populations. A separate six hour per week clinical lab component is a co-
requisite to Holistic Nursing: Infants and Children.  
 Select demographic data were analyzed as independent variables. Data collected 
at admission to the upper division of the nursing program included age, gender, race, 
marital status, number of children, employment status, previous degree attainment, and 
possession of a Licensed Practical Nurse license. 
 
Research Design 
This study was designed using a retrospective correlational approach. 
Correlational studies may be relationship studies or prediction studies. Relationship 
studies are used to determine if, and to what degree a set of variables are related (Gay & 
 57
Airasian, 2003). Predictive studies are used to determine if the relationships can make 
predictions. The variable used to make the prediction is the predictor variable. The 
criterion variable is the variable that is predicted (Gay & Airasian, 2003; Wallen & 
Fraenkel, 2001). Beginning with a basic correlation of the variables, those with high 
correlations are further studied as possible predictors of the criterion variable. 
Wallen and Fraenkel (2001) stressed that correlation studies do not establish 
cause and effect. The occurrence of a relationship between variables shown with a 
correlation study does not conclude that one variable caused another (Polit & Beck, 
2004). Caution should be taken with a prediction study because often a prediction 
equation is less accurate when used with a group other than the one on which it was 
originally developed (Gay & Airasian, 2003).  
Determining the qualities of an instrument used for predicting is imperative. 
Sensitivity and specificity are criteria used in evaluating screening instruments (Polit & 
Beck (2004). Sensitivity is the ability of the instruments to identify a case correctly. 
These are called true positives. The specificity of the instruments is the ability to identify 
those cases that do not possess the criterion. These are true negatives. Determining the 
cutoff point is necessary. The Receiver Operating Characteristic (ROC) curve illustrates 
the comparison at every cut off point (Simon, 2005). The comparison is helpful in 
discriminating between the two groups. There will be some cases that are correctly 
classified as true positives, some that are false positive. Also, some cases may be 
correctly true negatives and some are false negative (Schoonjans, 2006). The intent is to 
find the cut off point where most of the true positives and true negatives are found. The 
ROC curve is described the using the terms, sensitivity and specificity (Schoonjans, 
 58
2006). Sensitivity of the ROC curve is the probability that a test result will be positive 
(true positive). The specificity is the probability that a test result will be negative (true 
negative). Both of these terms are expressed as a percentage. Table 3 shows the 
classification of potential outcomes for the dependent variable used in the study. 
 
Table 3 
Classification for Potential Outcomes Using Sensitivity and Specificity 
Dependent Variable   n  n 
Successful True positive a False Positive c 
Unsuccessful False Negative b True Negative d 
Total  a + b  c + d 
  
The area of the ROC curve is determined by coordinates on the x and y axis. The 
accuracy of the test is determined by the area under the ROC curve. The larger the area, 
the more true positives while minimizing the false positives (Walld, 2001). Simon (2005) 
labels the area under the curve as fair (0.50 to 0.75), good (0.75 to 0.92), very good (0.92 
to 0.97), and excellent (0.97 to 1.00). 
 
Sampling 
 A convenience sample of students seeking admission to the upper division of the 
nursing program at one public southeastern urban university for the years of 2001, 2002 
and 2003 was selected for the study. To be included in the study, the students must have 
 59
completed the pre-requisite academic support courses with a 2.5 or higher, taken the 
HESI A
2
 examination, be accepted into the upper division of the nursing program. Those 
who withdrew from the junior nursing theory courses prior to completion of the junior 
year were removed from the sample.  
Convenience sampling is the most vulnerable form of sampling (Polit & Beck, 
2004). For this study, a convenience sample was used because the retrospective data 
existed from a group of students already formed (Gay & Airasian, 2003; Wallen & 
Fraenkel, 2001).  
 
Instrument 
HESI Admission Assessment
TM
 (HESI A
2
)  
HESI Admission Assessment
TM
 (HESI A
2
) is the instrument used in this study. 
The HESI A
2
 was first developed in 1999 as a measurement instrument to assist faculty 
in making pre-nursing student selection or academic course placement decisions (Nibert, 
2005). HESI tests are developed under the framework of Crocker and Algina?s (1986) 
classical test theory (Morrison, Adamson, Nibert, & Hsia, 2004). Students are assessed a 
twenty-five dollar fee for taking the HESI A
2
 (HESI, n.d.c.)  
The instrument is an examination containing two components: various academic 
content areas and personality inventory that includes assessments for learning style, 
personality style, and behavioral inventory (HESI, n.d.a.; HESI, 2003) (see Appendix A). 
The first component is the HESI A
2
 Content Examinations, which include mathematics, 
reading comprehension, vocabulary and general knowledge, grammar, general sciences 
 60
such as chemistry, anatomy and physiology (see Appendix B for the HESI A
2 
Faculty 
Scoring Guide).  
College and university professors who are considered experts in the basic 
academic fields, such as English, mathematics, biology, chemistry, anatomy and 
physiology and reading specialists author the test items for the academic content areas 
(Nibert, 2005). An item analysis is conducted on every HESI exam item that is returned 
to the company for a summary analysis (Morrison, Adamson, & Hsia, 2001). 
Additionally, each item is piloted prior to actual use on the instrument. Piloting the items 
for approximately one year allows for enhancement of the items based on student 
responses (Nibert, 2005).  
Each content area focuses on different cognitive skills needed to be successful in 
a nursing education program. The areas include basic math, reading comprehension, 
vocabulary, grammar, and selected sciences of chemistry and anatomy and physiology.         
The math component is a 50-item examination that concentrates on mathematics needed 
for calculating medications and solutions in nursing. Math skills that are assessed include 
addition, subtraction, multiplication, division, fractions, decimals, ratio and proportion, 
percentages, household measures and general math facts (Ables, Flick, Morrison, 
Rohlich, Tollett, Tollett, & Zivley, 2003) and are measured at the eight or ninth grade 
level (HESI, 2003).  
The reading comprehension is a 38-item examination, which includes reading 
health-related scenarios. The reading comprehension assesses the reading skills of 
identifying main ideas, finding the contextual meaning of words, identifying the purpose 
 61
of the writer, differentiating between fact and opinion, making inferences and ability to 
summarize (Ables, et al., 2003) at the eighth to ninth grade level (HESI, 2003).  
The vocabulary and general knowledge component is a 50-item exam containing 
basic vocabulary used in health care fields (HESI, 2003). Understanding these terms in 
appropriate contexts assists in accurate professional communication in the health care 
setting (Ables et al., 2003).  
The grammar examination contains items for basic English grammar and writing 
skills at the eighth or ninth grade level (HESI, 2003). Application of correct grammar 
usage and written communication, such as subject-verb agreement, plurality versus 
singularity, pronoun reference, misplaced modifiers, and punctuation depicts an educated 
individual, which is an expectation of health care recipients (Ables et al., 2003). 
Basic knowledge of the sciences necessary to make decisions regarding nursing 
care is assessed on the HESI A
2
. Chemistry, anatomy, and physiology are three subjects 
that are considered in the science component. Each of the subjects is comprised of 25 
items (HESI, 2003). The chemistry section assesses the basic knowledge of chemistry. 
Chemical equations, reactions, states of matter, periodic table, atomic structure, molar 
relationships, and acid/base compounds comprise the knowledge assessed (Ables et al., 
2003). The anatomy and physiology component examines the basic knowledge of 
anatomy and physiology of the human body. Examination items could include basic 
terminology, and concepts related to the integumentary, skeletal, muscular, nervous, 
endocrine, circulatory, respiratory, digestive, urinary, and reproductive systems (Ables et 
al., 2003).  
 62
Results of each HESI A
2
 content examination are generated in a percentage-based 
score (Nibert, 2005). Depending on the prerequisite courses for the nursing education 
program, specific content areas, such as the sciences, may be omitted from assessment of 
the student by the faculty. For example, if chemistry is not a prerequisite course, the 
chemistry examination may be omitted (Nibert, 2003). A cumulative score reflects the 
mean score for all the academic components selected by the faculty and taken by the 
student (Nibert, 2005). Appendix C is a sample HESI A
2
 score report. 
Results from the HESI A
2
 examinations can assist nursing faculty in making 
decisions about students seeking admission into nursing education programs. HESI 
recommends to nursing education programs two different uses for the HESI A
2
 Exam 
(Nibert, 2003). First, the HESI A
2
 was developed to assist in the selection of qualified 
applicants for nursing education programs. Nursing education programs can select to 
administer, to potential students, the exam components of the HESI A
2
 that relate to the 
prerequisites of the nursing curriculum. Admission criteria may consist of the cumulative 
score, which would include those content areas selected specifically for that nursing 
education program or may consist of the individual content scores. HESI?s 
recommendation for student selection is to combine the HESI A
2
 with other admission 
criteria. With this in mind, the cumulative score or individual content scores could be 
used in combination with GPA or other criteria for selecting students for admission 
(Nibert, 2003).  
The second recommendation for using the HESI A
2
 content examinations is for 
placement of potential students in courses that might enhance learning prior to admission 
into the rigors of the nursing curriculum (Nibert, 2003). The HESI A
2
 could determine  
 63
at-risk students. If students scored low on the math component or the reading 
comprehension portion, for example, remediation courses, tutoring, or study skills would 
benefit the student prior to admission into the nursing courses where those skills are 
needed. The HESI A
2
 may be able to determine those students who may be at risk for 
being unsuccessful.  
Longitudinal studies using the HESI A
2
 for tracking student progress throughout 
the nursing education program and through post-NCLEX results are limited because the 
instrument was recently developed (Nibert, 2005). Few cohorts of students have 
completed the nursing program and taken the NCLEX-RN. However, with the input of 
the authors of the content examinations and the faculty who first piloted the HESI A
2
, the 
developers of the HESI A
2
 determined that a cumulative score of 75% for students 
entering a registered nursing education program should be expected (Nibert, 2005). 
  There are few reliability and validity studies on the HESI A
2
. The reliability is 
computed statistically using the Kuder-Richardson Formula 20 (KR-20) (Nibert, 2003). 
For each test administered, a KR?20 is calculated and added to estimate the average    
KR?20.  
The formula used by HESI to calculate the KR-20 is 
R=N/(N-1) * (F(s)- Sum (PQ))/F (s)  
Where:  
N = number of test items 
P = Correct responses-Number of test takers 
Q = 1-P F (s) = Mean of the estimated standard deviations  
(Morrison, Adamson, & Hsia, 2001). 
 64
Kuder-Richardson formulas estimate the coefficient of equivalence particularly when all 
the items in a test represent a single general factor (Cronbach, 1949).  
KR?20 statistics for the HESI A
2
 content examinations are based on unpublished 
studies in 2002 (Nibert, 2003), in 2003 (Murray & Nibert, 2003) using data from an 
associate degree nursing (ADN) education program, and in 2004 (Yoho & Young, 2004) 
using data from an ADN and baccalaureate degree nursing (BSN) education program 
(HESI, 2005). The KR?20 reliability coefficients are shown in Table 4. 
 
Table 4 
KR-20 for HESI A
2 
by Examination Component 
HESI A2 Examination 
Component 
2002 ADN 
Program* 
2003 ADN 
Program** 
2004 ADN and 
BSN Program** 
Math 0.95 0.93 0.99 
Reading Comprehension 0.92 0.90 0.99 
Vocabulary/General 
Knowledge 
0.98 0.95 0.99 
Grammar 0.97 0.97 0.99 
Chemistry 0.94 N/A 0.99 
Anatomy and Physiology 0.94 0.96 0.98 
* Nibert, 2003 
** HESI, 2005 
 
 
 65
Correlation studies of the HESI A
2
 content examinations to nursing course grades 
are underway or have been recently completed. Murray and Nibert (2003) studied the 
cumulative score for six of the academically-oriented examinations: math, chemistry, 
anatomy and physiology, grammar, reading comprehension and vocabulary and general 
knowledge. The study used 52 students from one associate degree nursing program to 
compare the HESI A
2
 score with all final nursing course grades. The correlations were 
statistically significant (p = .05) for all course grades with the exception of the grade in 
Therapeutic Communications and Principles of Adult Health (Murray & Nibert, 2003).  
Two correlation studies on the correlation of the HESI A
2
 with the HESI 
Specialty Examinations and the HESI Exit examination have been reported (Nibert, 
Murray, & Merriman, 2005; Yoho & Young, 2004). Nibert, Murray, and Merriman found 
that significant correlations (p < .05) among all HESI exams administered within the 
curriculum and final course grades in corresponding courses with the exception of 
Therapeutic Communications in the associate degree program. The Baccalaureate 
program showed significant correlations (p < .05) with all the HESI exams and final 
course grades. Results from the Yoho and Young (2004) study have not been published.  
The second component of the HESI A
2 
is the personal inventory that consists of 
learning styles, personality styles, and behavioral inventories (HESI, n.d.a.; HESI, 2003). 
This component offers students awareness about their learning preferences, study habits, 
and behavioral dispositions as they relate to academic achievement. The developers of 
the HESI A
2
 iterate that this component is not intended as a psychological assessment, or 
detecting a learning disability, or a referral for such activities (Nibert, 2003). Scoring for 
the personal inventory component is found in Appendix D. 
 66
The learning styles are determined by a 14-item assessment component of the 
HESI A
2
 (HESI, 2003). Students are assessed as being visual, auditory, kinesthetic, 
cognitive, analytical, or global learners. Written explanations of these categories include 
a description of the specific type of learner and suggestions for studying that best suits 
this type of learner. These explanations are provided to the students with the results of the 
HESI A
2
 (HESI, n.d.b). 
The personality styles component is a 15-item measurement of personality as it 
pertains to the preferred learning style (HESI, 2003). The categories for personality types 
according to HESI are people person, leader, creative, and calm. Those in the people 
person group have a dominant personality type in the talking group. The leader group 
have a dominate personality type that is in the working group. The creative person is in 
the thinking group. The calm person is in the watching group. Written explanations for 
the groups include strengths, weaknesses, strong characteristics, and suggestions for 
improving the type of learning style. 
The behavioral inventory provides an overall numerical score from a 56-item test 
of students? behaviors and values (HESI, 2003). Sub-categories are scored and include 
decision making, emotional health, depression and stress. The overall score results 
indicate how well a student will handle the rigors of nursing school (HESI, n.d.b). 
 
Procedures 
Permission to use archival data and to conduct the study on site was obtained 
from the Dean of the selected nursing education program. A proposal for the study was 
sent to the Institutional Review Board for the Use of Human Subjects in Research (IRB) 
 67
of the University used in the study requesting an exemption status as data already 
collected would be used. The status of exemption was granted (see Appendix E).  
In addition, an appeal for exempt status was requested from the Auburn 
University Institutional Review Board for Research Involving Human Subjects to meet 
the requirement for performing research at the University. Approval was granted in May 
2005 (see Appendix F). 
All data were entered on an Excel spreadsheet by the researcher. Student records 
were coded to assure anonymity. Identifying data were deleted from the spreadsheet.  
Demographic data were collected from student records used for admission to the 
School of Nursing and entered on the spreadsheet. Specific demographic data included 
gender, ethnicity, age at admission to the nursing education program, marital status, 
number of children, previous baccalaureate degree, and if practicing as a Licensed 
Practical Nurse (LPN). Categorical data such as gender ethnicity, marital status, previous 
degree, and LPN status were coded.  
Course grades and GPA were obtained through the nursing education program 
Student Advisor. Electronic data from the university record keeping software program 
located in the registrar?s office of the University was used. Results of the HESI A
2
 data 
are generated by Health Education Systems, Inc. and sent to the Dean of the nursing 
education program. Student records with scores from the HESI A
2
 were obtained from 
the Dean?s office at the School of Nursing. 
 
 
 
 68
Analysis 
Analysis of the data was completed using SPSS, a statistical software package. 
Descriptive and inferential statistics were used. Descriptive statistics to characterize the 
sample included the means, standard deviations and ranges for certain data.  
Inferential statistical analyses began with Pearson Product Moment Correlation 
Coefficients to determine the extent of the relationship between the independent variables 
and the dependent variables. For those relationships that were significant, multivariate 
procedures were used. The most common type is multiple regression which is used to 
understand the effects of two or more independent variables on a dependent variable. 
Regression is used to make predictions about occurrences (Polit & Beck, 2004); the 
higher the correlation between the variables, the more accurate the prediction. More 
specifically, logistic regression was used to determine the predictability of the admission 
GPA, HESI A2 cumulative score, other HESI related factors, and grades for nursing 
theory courses on success in the junior year of the nursing program. Completion of the 
junior nursing courses is either yes or no, therefore, the dependent measure is of a 
categorical measure and suitable for logistic regression (Pedhazur, 1997).  
 
Summary 
 Chapter III of the study included a description of the participants used in the study 
and the procedures for obtaining the data from archival records. Success in the junior 
year of the nursing program, the dependent or criterion variable, was defined and 
described using the nursing courses included during the junior year. The independent or 
predictor variables used in the study were described. These variables included the 
 69
admission GPA for the nursing program and the instrument used in the study, the HESI 
A
2
 examination. Demographic data and additional components of the HESI A
2
 were also 
used in the study and described in the chapter. The type of correlation and regression 
model used for data analysis was also discussed. 
 70
 
 
 
 
 
 
 
 
 
IV. RESULTS 
 
Introduction 
 The purpose of this study was to examine the relationship between the 
prerequisite academic support courses for a nursing program and the HESI A
2 
as a 
predictor of success in the first year of a baccalaureate nursing education program. This 
study also identified demographic characteristics, nursing theory course grades, and HESI 
A
2
 based factors that can be used to predict first year student success.  
The results will examine the relationship between the independent variables 
(admission GPA, HESI A
2
 cumulative score, nursing theory course grades, demographic 
characteristics, and other HESI A
2 
based scores) and the dependent variable. The 
dichotomous dependent variable is described as being successful or not successful in the 
junior year of a nursing education program. Success in the junior year is completing all 
nursing theory and clinical courses in the junior year of the nursing program with a C or 
better. 
 
Participants 
 One hundred sixty three participants met the initial criteria for admission and 
were admitted into the nursing education program. For the purposes of the study, data 
 71
from one hundred twenty eight participants? records were analyzed. The final number in 
the sample was limited due to missing or incomplete data. 
The demographic characteristics of the sample were retrieved from the records. 
Data included age, gender, race, marital status, number of children, employment, 
previous degrees held, and status as a licensed practical nurse (LPN). The mean age of 
the students in the sample was 24.9 (SD = 6.23) with a range of 37 years. The range in 
years included from 20 to 57. The participants were predominately female (91.4 %, n = 
117). The majority of the participants were Caucasian (79.7%, n = 102). African 
American represented the largest number of ethnic minorities with 16.4% (n = 21). Other 
ethnic groups represented were American Indian, Asian American, and Hispanic. Sixty-
six percent (n = 85) of the sample have never been married. Twenty-five and one half 
percent (n = 33) of the participants have at least one child with eight percent having three 
or more children. Approximately sixty-two percent (n = 79) of the sample were employed 
either full or part time. The data showed that eighteen percent (n = 23) hold previous 
baccalaureate degrees. Seven (5.5%) of the participants are licensed practical nurses 
seeking the baccalaureate registered nursing degree. Table 5 depicts the demographic 
characteristics of the sample. 
 
 72
Table 5 
Demographic Characteristics of Sample  
Characteristic Total 
N = 128 
Percent 
Age M = 24.9 
 
 
Gender:  Male  11  8.6 
Female 117 91.4 
Race:  White 102  79.7 
Non-White  26 20.3 
Marital Status   
Never Married 85 66.4 
Married 39 30.5 
Divorced 4 3.1 
Number of Children    
None 95 74.2 
One 14 10.9 
Two  9  7.0 
Three  8  6.3 
Four   2   1.6 
Employment   
Not Employed 49  38.3 
Full Time 27  21.1 
Part time 52  40.6 
Previous Degree   
No 105 82.0 
Yes 23 18.0 
LPN 
No 121 94.5 
Yes   7  5.5 
 73
Research Questions 
 The data were analyzed to address the four research questions focused on the 
study. The research questions examine the relationship between the independent variables 
(admission GPA, HESI A
2
 cumulative score, nursing theory course grades, demographic 
characteristics, and other HESI A
2
 based scores) and the dependent variable (success in 
the junior year of the nursing program). 
Research Question One 
Results of the data analysis addressed Question 1, which is stated, ?What is the 
relationship between the admission GPA and the HESI A
2
 for nursing students?? The 
admission grade point average (GPA) is calculated from the grades in the pre-requisite 
academic support courses for nursing. These pre-requisite academic support courses 
include English composition, English literature, a fine arts elective, history, government, 
sociology, general psychology, finite math, biology, introduction to chemistry, nutrition, 
anatomy and physiology I, anatomy and physiology II, microbiology, and developmental 
psychology. The sample mean admission GPA is 3.16 (SD .40). The range of the GPA is 
2.5 to 4.0. 
The HESI A
2
 is an examination administered after completion of all the pre-
requisite courses and prior to beginning the first nursing theory course. The components 
of the HESI A
2
 used in this study include mathematics, reading comprehension, 
vocabulary, grammar, chemistry, and anatomy and physiology. A cumulative score from 
the HESI A
2
 includes scores in the above areas. The mean HESI A
2
 cumulative score for 
the sample is 75.6 (SD = 7.2). The range of the HESI A
2
 cumulative scores is 55.1 to 
89.2. 
 74
The relationship between the means of the admission GPA and the HESI A
2
 was 
analyzed using a Pearson Product Moment Correlation. The correlation of the admission 
GPA and the HESI A
2
 score were statistically significant (r = .450, p = .01). Table 6 
identifies the means and standard deviations of the Admission GPA and the cumulative 
score from the HESI A
2
.  
 
Table 6 
Comparison of Admission Grade Point Average and Cumulative HESI A
2
 Score  
Variable Total (N = 128) r 
 M (SD)  
Admission GPA 3.16 (.40) 
HESI A
2
 Score    75.6 (7.20) 
 
.450* 
* p = .01(2-tailed) 
 
To address the last three research questions, the dichotomy of the dependent 
variable divided the participants into groups. The first group included the participants 
who successfully completed the junior nursing theory and clinical courses with a grade of 
C or better, n = 105 (82%). The second group consisted of those individuals who were 
not successful in completing the junior nursing theory and clinical courses with a C or 
better, n = 23 (18%).  
 75
Research Question Two 
The second research question was, ?What is the relationship between the 
admission GPA and success in the first year of the nursing education program?? An 
independent samples t-test was performed to determine if there was a statistically 
significant difference between the mean GPA of those who were successful in the junior 
year of the nursing program and those who were not. The mean of the admission GPA for 
those participants who were successful in the junior year of the nursing program was 3.22 
(SD = .40). The mean of the admission GPA for those participants who were not 
successful in the junior year was 2.89 (SD = .31). An independent samples t-test of the 
admission GPA for students who were successful in the junior year with those who were 
not was statistically significant (t = 3.8 (126), p < .001). Using ANOVA, test of between 
subjects effects showed a statistically significant difference (F (1, 128) = 14.112, p < 
.001). The effect size revealed ?
2
 = .101 with an observed power of .961.  
Further analysis was performed using logistic regression to determine the effect of 
the independent variable, admission GPA, on success at the end of the junior year. The 
admission GPA was statistically reliable in distinguishing between those who were 
successful in the junior year and those who were not (-2 log Likelihood = 105.936; ?
2
 (1) 
= 14.619, p = .001). The admission GPA predicted an overall percentage correct of 82.  
The Receiver Operating Characteristic (ROC) curve illustrates the sensitivity and 
specificity of the admission GPA with success in the nursing education program used in 
the study. Coordinates of the curve are derived from the data analysis. Figure 1 is the 
graph of the ROC curve for admission GPA. The area under the curve is .739, p < .000. 
ROC Curve
Diago nal segments are produced by  ties.
1 - Sp ecificity
1.00.75.50.250.00
Se
n
s
itiv
it
y
1.00
.75
.50
.25
0.00
So ur c e o f  t h e C ur v e
Reference Line
ADMISSION GPA
Figure 1. ROC Curve for Admission GPA 
 
The nursing program selected for the study used admission GPA as criterion for 
selecting students who will be admitted into the nursing education program. Admission 
into the program required a 2.5 GPA on the pre-nursing academic support courses. The 
data were analyzed to determine what GPA cut-off would best delineate those who would 
be successful in the junior year of the nursing program and those who would not. Table 7 
shows the selected GPA cut-off points, sensitivity, specificity, and the percent of 
predicted probability.  
 
 76
 77
Table 7 
Admission GPA and Outcome: Cutting GPA, Sensitivity, Specificity, and Predicted 
Probability 
Successful Not successful
Cutting 
Admission GPA
N = 128 
Sensitivity 1 -Specificity Predicted 
Probability 
 
? 3.25 50  3 .48 .13  89% 
? 3.0 68 9 .65 .39  80% 
? 2.75 94  15 .90 .61  68% 
? 2.7 98  16 .93 .65  65% 
? 2.65 99  17 .94 .74  62% 
? 2.6 102  19 .97 .78  58% 
? 2.55 102  20 .97 .87  58% 
> 2.5 105 23 .98 .95  53% 
 
 
Research Question Three 
Research Question 3, ?What is the relationship between the HESI A
2
 scores and 
students who were successful in the first year of the nursing education program and those 
who were not??, is addressed using an independent t test and logistic regression. The 
binary dependent variable divided the participants into groups. The first group included 
the participants who successfully completed the junior nursing theory and clinical courses  
 
 78
with a grade of C or better and the second group consisted of those individuals who were 
not successful in completing the junior nursing theory and clinical courses with a C or 
better.  
The mean for the HESI A
2
 cumulative score for the participants who successfully 
completed the junior year was 76.50 (SD = 7.18). The mean HESI A
2
 cumulative score 
for the group that was not successful in completing the junior year course work was 71.4 
(SD = 5.74). An independent t-test on the means of the two groups was statistically 
significant (t = 3.2 (126) p = .002). Using ANOVA, test of between subjects effects 
showed a statistically significant difference (F (1, 128) = 10.173, p=.002). The effect size 
revealed ?
2
 = .075 with an observed power of .886. 
Further analysis was performed using logistic regression to determine the effect of 
the independent variable, HESI A
2
 cumulative score, on success at the end of the junior 
year. The HESI A
2
 cumulative score was statistically reliable in distinguishing between 
those who were successful in the junior year and those who were not (-2 log Likelihood = 
111.182; ?
2
 (1) = 9.374, p = .003). The HESI A
2
 cumulative score predicted an overall 
percentage correct of 79.7.  
The ROC curve illustrates the sensitivity and specificity of the HESI A
2
 with 
success in the nursing education program used in the study. Coordinates of the curve are 
derived from the data analysis. Figure 2 is the graph of the ROC curve for the HESI A
2
 
cumulative score GPA. The area under the curve is .720, p = .001. 
 
Figure 2.  ROC Curve for HESI A
2 
Cumulative Score 
ROC Curve
Diagonal segments are produced by ties.
1 - Specificity
1.00.75.50.250.00
S
e
n
s
iti
v
i
ty
1.00
.75
.50
.25
0.00
Source of the Curve
Reference Line
HESI A2
 
The data was analyzed to determine what HESI A
2
 cumulative score cut-off 
would best delineate those who would be successful in the junior year of the nursing 
program and those who would not. Health Education Systems, Inc. the developers of the 
HESI A
2
 determined that a cumulative score of 75% for students entering a registered 
nursing education program should be expected (Nibert, 2005). Table 8 shows the selected 
HESI A
2
 cut-off points, sensitivity, specificity, and the percent of predicted probability.  
 
 79
 80
Table 8 
HESI A
2
 Cumulative Score and Outcome: Cutting Score, Sensitivity, Specificity, and 
Predicted Probability 
Successful Not 
Successful 
Cutting 
HESI A
2
 Score 
N = 128 
Sensitivity 1-Specificity Predicted 
Probability 
 
? 80 37  1 .35 .04  89% 
? 75 67 7 .64 .26  83% 
? 70 87  12 .82 .52  75% 
? 65 99  20 .94 .87  67% 
? 60 102  23 .97 1.0  55% 
> 55 105 23 1.00 1.0  41% 
 
 
The variables in Research Question Two and Three were further compared using 
Logistic regression to determine if the admission GPA, the HESI A
2
 cumulative score, or 
a combination of the two would be a better predictor of success in the junior year of the 
nursing program. When the admission GPA and the HESI A
2
 cumulative score were 
added to the model together a lesser statistically significance occurred (-2 Log Likelihood 
= 102.625; ?
2
 = 17.93). The admission GPA and HESI A
2
 cumulative score combined 
predicted an overall percentage correct of 79.7. Table 9 shows the logistic regression 
analysis of the two variables. Table 10 depicts the percentage of correct prediction based 
on each variable and combination of the two variables.  
 81
Table 9 
Logistic Regression Analysis of Admission GPA and HESI A
2
Variable ?
2
Beta p 
value
odds     
ratio 
95% CI % predicted 
correctly 
-2 log 
Likelihood
Admission 
GPA 
14.619 2.595 .001 13.397 2.919, 61.495 82 105.936 
HESI A
2
9.374  .099 .003 1.104 1.034,   1.179 79.7 111.182 
Admission 
GPA and HESI 
A
2
  
 
17.930 
2.197 
 
 .068 
.007 
 
.071 
8.997 
 
1.070 
1.820, 44.467 
 
0.994,   1.152 
 
79.7 
 
102.625 
 
Table 10 
Percentage of Correct Prediction Based on Admission GPA and HESI A
2
  
 
Admission 
GPA                   HESI A
2
Admission GPA 
and HESI A
2
 
 
 
0* 1** 
Percent 
Correct 
 
0* 
 
1** 
Percent 
Correct 
 
0* 
 
1** 
Percent 
Correct 
0* 0  23 0 0 23 0 1 22  4.3 
1** 0 105 100 3 102 91.1 4 101 96.2 
Overall  
Percent   
82   79.7   79.7 
0* = Not Successful 
1** = Successful 
 
 The ROC curve for the admission GPA and HESI A
2
 illustrates the overlap of the 
two variables and close proximity. The difference in the areas equals .019. Figure 3 
shows how the two variables coincide. 
 
ROC Curve
Diagonal segments are produced by ties.
1 - Specificity
1.00.75.50.250.00
S
e
n
s
it
iv
i
ty
1.00
.75
.50
.25
0.00
Source of the Curve
Reference Line
Admission GPA
HESI A2 
 
Figure 3. ROC Curve for Admission GPA and HESI A2 
 
Research Question Four 
The fourth question, ?What demographic characteristics, nursing theory course 
grades, and HESI A
2
 based factors are predictive of success in the first year of the 
nursing education program?? is addressed. Three sets of variables are discussed and 
analyzed for significance: demographic characteristics, nursing theory course grades for 
the junior year, and HESI A
2
 based factors that include the separate academic related 
 82
 83
components of the cumulative score from the
 
HESI A
2 
examination and learning styles, 
personality profiles and the behavioral score. 
The demographic characteristics consisted of age, gender, race, marital status, 
number of children, employment, previous degrees held, and status as a licensed practical 
nurse (LPN). Table 11 shows the frequencies of the characteristics according to those 
who were successful in the first year of the nursing program and those who were not. 
 
Table 11 
Frequencies of Demographic Characteristics by Outcome Group 
Demographic Characteristic Successful 
(n = 105) 
Unsuccessful 
(n = 23) 
Age M = 25 M = 24.6 
Gender   
Male 8 (7.6%) 3 (13%) 
Female   97 (92.4%)   20 (87%) 
Race   
White  88 (83.8%)   14 (60.9%) 
Non-White  17 (16.2%) 9 (39.1%) 
Marital Status   
Never Married 69 (65.7%) 16 (70%) 
Married 32 (30.5%) 7 (30%) 
Divorced 4 (3.8%) 0 
(table continues) 
 84
Table 11 (continued) 
Demographic Characteristic Successful 
(n = 105) 
Unsuccessful 
(n = 23) 
Number of Children    
None 76 (72.4%) 19 (82.6%) 
One or more 29 (27.6%) 4 (17.4%) 
Employment   
Not Employed 36 (34.3%) 13 (56.5%) 
Full Time or Part time 69 (65.7%) 10 (43.5%) 
Previous Degree   
          Yes 22 (20.9%) 1 (4.3%) 
          No 83 (79.1%) 22 (95.7%) 
LPN   
Yes 6 (5.7%) 1 (4.3%) 
No  99 (94.3%) 22 (95.7%) 
 
Further data analysis on the demographic characteristics revealed information to 
address Research Question Four. An independent samples t test was used on the age 
category and yielded no statistically significant difference between those who were 
successful and those who were not successful (p = .778). A chi-square cross tabs analysis 
for the categories with dichotomous data was used. The sample size and small number of 
responses did not allow for an analysis in the categories of gender, race, marital status, 
previous degree, and LPN status. Work status and number of children were not 
statistically significant between those who were successful and those who were not. 
The junior year nursing theory course grades comprise another group of 
independent variables. In the fall semester of the junior year, the students enroll in 
 85
Pathophysiology, Nursing Skills, Holistic Assessment, and Professional Nursing 
Concepts I. The grades for the nursing courses taught in the spring semester of the junior 
year and used in the study include Pharmacology, Holistic Nursing: Adults and 
Geriatrics, and Holistic Nursing: Infants and Children.  
An independent samples t-test was performed to determine if there was a 
difference between those who were successful in the junior year and those who were not 
on any of the nursing course grades. Table 12 compares the junior year nursing theory 
grades for the group that was successful with the group who were not successful. The 
results showed that all of the nursing course grades were statistically significant. The 
effect size addresses the strength of relationships among the variables. Cohen?s effect 
size values of .2, .5, and .8 indicate a small, medium, or large effect size, respectively 
(Polit & Beck, 2004). All nursing courses had a large effect size. 
 
 86
Table 12 
Comparison of Junior Year Nursing Theory Course Grades by Group 
  
 
   
 
 
  Levene?s Test for Equality 
of Variances 
 
 
Junior Year 
Nursing Theory 
Courses 
Successful 
(n = 105) 
M (SD) 
Unsuccessful
(n = 23) 
M (SD) 
 
 
t 
 
 
df 
p (2- 
tailed)
 
 
F 
 
  
 p 
 
 
d 
Pathophysiology 85.7 (5)
a
79 (3.6) 6.093 125 .000 3.718 .056 1.54 
Nursing Skills 88.6 (4.7) 84.3 (4.6) 3.954 126 .000 .004 .948 0.92 
Professional 
Nursing Concepts I  
87.7 (4.5) 82.9 (3.5) 4.765 126 .000 2.041 .156 1.19 
Pharmacology 83.8 (5.2)
a
77 (8.8) 4.916 125 .000 2.794 .097 0.94 
Holistic Nursing: 
Adults and 
Geriatrics 
83.6 (5) 73.8 (7.7) 7.600 126 .000 1.128 .290 1.51 
Holistic Nursing: 
Infants and 
Children 
81.4 (3.8) 72.4 (4) 8.285 126 .000 .207 .630 2.31 
a
n = 104 
 
 
The HESI A
2
 examination is comprised of separate academic related components. 
The HESI A
2
 components used in this study include Mathematics, Reading 
Comprehension, Vocabulary, Grammar, Chemistry, and Anatomy and Physiology. An 
independent samples t-test was computed for the means between those who were 
successful in the junior year and those who were not on each content area of the HESI A
2
.  
Table 13 shows the results of the comparison of the components for those who were 
 87
successful in the junior year and for those who were unsuccessful. The mean was not 
statistically significant for the Reading Comprehension component. A statistically 
significant difference was found in the Math, Vocabulary, Grammar, Chemistry, and 
Anatomy and Physiology components, although the effect size values are small to 
medium. 
 
Table 13 
Comparison of the HESI A
2
 Content Examinations by Group 
    Levene?s Test for Equality 
of Variances 
 
HESI A
2
 
Content 
Examinations 
Successful 
n = 105 
M (SD) 
Unsuccessful 
n = 23 
M (SD) 
 
t 
 
df 
 
 
p (2-
tailed) 
 
F 
 
p 
 
d 
Math 84.7 (12.1) 78.3 (12.4) 2.285 126 .024   0.446 .505 .52 
Reading  82.8 (8.5) 80.2 (7.6) 1.338 126 .183   1.118 .292 .32 
Vocabulary  76.5 (10.1) 70.1 (10.4) 2.726 126 .007   0.094 .760 .62 
Grammar  92.3 (4.5) 88.2 (9.4) 3.140 126 .002   11.301 .001 .55 
Chemistry  67.2 (13.6) 58.2 (13.1) 2.899 126 .004 0.304 .582 .67 
Anatomy & 
Physiology 
64.2 (13.6)
a
59.1 (10.6) 2.094 124 .038   0.236 .628 .42 
a
 n = 104 
 
An additional part of the HESI A
2
 is the Personality Profile and included learning 
styles, personality styles, and behavioral inventories. The personality styles and learning 
 88
styles were categorical and had to be coded for use in the analysis. The score from the 
Behavioral Inventory allowed for a statistical analysis without coding.  
The developers of the HESI A
2
 convey the results of the learning style types in 
two groupings. The first grouping consisted of auditory, cognitive, kinesthetic, or visual 
type of learners. The second grouping was analytical or global type. Table 14 shows the 
frequency of learning style types of the total sample and divided by those who were 
successful and those who were not successful in the first year of the nursing program.  
 
Table 14 
Frequencies of Learning Style Types by Group and Total  
Grouping I Successful 
(n = 103) 
Unsuccessful 
(n = 23) 
Total 
(n = 126) 
Auditory 26 (25.2%) 5 (21.7%) 31 (24.6%) 
Cognitive 16 (15.5%) 1  (4.3%) 17 (13.5%) 
Kinesthetic 53 (51.5%) 14 (60.9%) 67 (53.2%) 
Visual 8   (7.8%) 3 (13.1%) 11  (8.7%) 
Grouping II    
Analytic 51 (49.5%) 5 (21.7%) 56 (45.3%) 
Global 52 (50.5%) 18 (78.3%) 70 (54.7%) 
 
The small sample and number of responses in certain cells did not allow for an 
analysis of the Group I learning styles. A majority of the sample was kinesthetic style 
learners. 
 89
A chi square analysis of the second grouping (analytical vs. global) and outcome 
(successful vs. unsuccessful) showed a statistically significant relationship between the 
learning style and the outcome (?
2
 = 6.3, p < .05). The data analysis further documents 
that the Odds Ratio is 3.67 (95% CI = 1.3, 10.6) indicating that those who did not 
succeed were almost 4 times more likely to have a global learning style rather than an 
analytical learning style. 
The Personality Profile of the HESI A
2
 included four categories: calm person, 
creative person, lead person, and people person. The assignment of the category is 
determined by the dominate personality type. Table 15 shows the frequencies and 
percentages of the personality style type by the outcome group. A chi square analysis 
revealed an insufficient number of cases in at least one cell. 
 
Table 15 
Frequencies of Personality Types by Outcome Group 
 
 
Personality Type 
Successful 
(n = 103) 
Unsuccessful 
(n = 21) 
Total 
(n = 124) 
Calm 17 (16.5%) 3 (14.3%) 20 (16.1%) 
Creative 27 (26.2%) 4 (19.1%) 31 (25.0%) 
Lead 36 (35.0%) 7 (33.3%) 43 (34.7%) 
People 23 (22.3%) 7 (33.3%) 30 (24.2%) 
 
 90
The third component of the Personality means for the Behavioral Inventory for 
those who were successful and those who were not successful were 6.8 (SD =1.5) and 6.8 
(SD 1.3), respectively. Results from independent samples t-test for the Behavioral 
Inventory score showed no statistically significant difference between the means for the 
two groups (t = -.303 (124), p = .762). An ANOVA revealed no statistically significant 
difference between groups (F (1, 126) = .092, p = .762). The effect size showed ?
2 
= .001 
with an observed power of .06. 
 
Summary 
Results of the data analysis for the study to determine if the admission GPA, 
HESI A
2
 cumulative score or demographic characteristics, nursing theory course grades, 
and HESI A
2
 based factors can be used to predict first year student success. Logistic 
analysis, chi square, and an independent samples t-test were used to analyze the data. An 
alpha level of .05 was set. From the sample, the correlation of the admission GPA and 
HESI A
2
 cumulative score was found to be statistically significant. As compared with the 
dependent variables, being successful or not being successful in the junior year of the 
Baccalaureate nursing program, both independent variables showed a statistically 
significance difference. 
Other variables were analyzed. The demographic factors showed too few 
participants in one or more categories to provide an analysis of whether or not a 
statistically significant difference between those who were successful and those who 
were not. All the nursing course grades were statistically significant. The Holistic 
Nursing: Infants and Children course had the highest effect sizes (see Table 12). One of 
 91
the individual components of the HESI A
2
 cumulative score, reading, was not statistically 
significant. The other components of the HESI A
2
 cumulative score were statistically 
significant with small to medium effect sizes (see Table 13). The learning styles analysis 
showed too few numbers in at least one of the cells to be valid. However, from the 
descriptive analysis of the frequencies, the majority of those in the sample were 
kinesthetic learners. There was not a statistically significant difference between the 
means of the behavioral inventories. Chapter V includes the purpose of the study, 
summary of the study, a discussion of the results, recommendations for further study, and 
recommendations for faculty teaching in nursing education programs. 
 
 92
 
 
 
 
 
 
 
 
 
V. SUMMARY, DISCUSSION, AND RECOMMENDATIONS 
 
Purpose of the Study 
The purpose of this study was to examine the relationship between the 
prerequisite academic support courses for a nursing program and the HESI A
2 
as a 
predictor of success in the first year of a baccalaureate nursing education program. This 
study also identified demographic characteristics, nursing theory course grades, and HESI 
A
2
 based factors that can be used to predict first year student success. 
 
Summary 
The participants included three cohorts of students seeking admission into a 
baccalaureate nursing education program during the fall of 2001, 2002, and concluding 
with the fall 2003. A total of 128 students met the criteria for inclusion in the sample. The 
demographic characteristics of the sample included age, gender, race, marital status, 
number of children, employment, previous degrees held, and status as a licensed practical 
nurse (LPN).  The mean age of the students in the sample was 24.9 (SD = 6.23) with a 
range of 37 years. The range in years was from 20 to 57. The participants were 
predominately female (91.4 %, n = 117).  The majority of the participants were 
Caucasian (79.7%, n = 102). African American represented the largest number of ethnic 
minorities with 16.4% (n = 21). Other ethnic groups represented were American Indian, 
 93
Asian American, and Hispanic. Sixty-six percent (n = 85) of the sample have never been 
married. Twenty-five and one half percent (n = 33) have one or more children with eight 
percent having three or more. Approximately, sixty-two percent (n = 79) of the sample 
are employed either full or part time. The data showed that eighteen percent (n = 23) hold 
previous baccalaureate degrees. Seven (5.5%) of the participants are licensed practical 
nurses seeking the baccalaureate registered nursing degree.  
The sample was divided into two groups for the study. The first group included 
the participants who successfully completed the junior nursing theory and clinical courses 
with a grade of C or better, n = 105 (82%). The second group consisted of those 
individuals who were not successful in completing the junior nursing theory and clinical 
courses with a C or better, n = 23 (18%). Success in the junior year nursing courses was 
the outcome variable. 
The GPA of the pre-requisite academic support courses used for admission into 
the nursing education program was one of the predictor variables analyzed in the study. 
The admission GPA is calculated by dividing the total number of grade points for the 
prerequisite courses by the total number of the credit hours of the pre-requisite courses. 
The prerequisite academic support courses include English composition, English 
literature, a fine arts elective, history, government, sociology, general psychology, finite 
math, biology, introduction to chemistry, nutrition, anatomy and physiology I, anatomy 
and physiology II, microbiology, and developmental psychology.  
The second predictor variable was the cumulative score from the HESI A
2
. The 
HESI A
2
 is an examination containing two components: various academic content areas 
necessary for nursing students and assessments for learning style, personality profile, and 
 94
behavioral inventory (HESI, n.d.a.; HESI, 2003). The HESI A
2
 cumulative score includes 
the academic content areas only.  
Additional available data were studied to determine factors that can predict first 
year success in a nursing education program. Data analyzed included demographic 
characteristics (age, gender, race, marital status, work status, number of children, 
previous degree, and LPN status), nursing theory course grades (Pathophysiology, 
Nursing Skills, Holistic Assessment, Professional Nursing Concepts I, Pharmacology, 
Holistic Nursing: Adults and Geriatrics, and Holistic Nursing: Infants and Children), and 
HESI A
2
 based factors (learning styles, personality styles, and behavioral inventory).   
Pearson R correlations, logistic regression, and a one-way multivariate analysis of 
variance were used to determine statistically significant predictors based on the following 
research questions:  
1. What is the relationship between the admission GPA and the HESI A
2
 for 
nursing students? 
2. What is the relationship between the admission GPA and success in the 
first year of the nursing education program?  
3. What is the relationship between the HESI A
2
 scores and students who 
were successful in the first year of the nursing education program and those who were 
not?  
4. What demographic characteristics, nursing theory course grades, and 
HESI A
2
 based factors are predictive of success in the first year of the nursing education 
program?  
 
 95
Discussion  
Faculty in nursing education programs are challenged with identifying criteria for 
admission into the program. The grades from the pre-nursing academic support courses 
calculated into the cumulative GPA of the pre-nursing courses is readily available for use 
as admission criteria and used in many nursing education programs. Statistical analysis of 
the cumulative GPA in this study showed a moderate correlation with the HESI A
2
 
cumulative score. There was a statistically significant relationship with admission GPA 
and success in the junior year of the nursing education program. Use of the cumulative 
GPA of the pre-nursing academic support courses as admission criteria was supported in 
this study. 
The HESI A
2
 cumulative score is another variable studied for use as admission 
criteria. As with the cumulative admission GPA, the HESI A
2
 cumulative score showed a 
statistically significant correlation with success in the junior year of the nursing education 
program. The HESI A
2
 cumulative score for admission criteria into the nursing program 
was supported in this study. 
A determination of which one of the two variables is the best choice for admission 
criteria should be made based on statistical analysis and practicality. Both the admission 
GPA and the HESI A
2
 cumulative score showed a statistically significant relationship 
with success in the junior year of the nursing program and could be used as admission 
criteria. The HESI A
2
 requires financial expense on the part of the student and faculty or 
staff time at the school or university to administer the examination under proctored 
conditions. Additional statistical analysis of the two variables together with success in the 
 96
junior year did not show an increase in the percentage of correct prediction over the 
admission GPA alone. 
The demographic variables showed too few participants in the sample to provide 
an analysis or an absence of a statistically significant difference between the two groups. 
In the study, however, the frequencies in the descriptive statistics revealed that the 
sample contains a variety of adult learners. Long (2004) discusses the variations of adult 
learners in terms of motives for learning, personalities, experiences, and roles. The 
demographics of the sample in the study validated these variations that are described by 
Long. From the learning motivation and experiential aspect, all learning styles are 
represented in the sample, eighteen percent of the sample hold previous degrees and five 
percent are already licensed as LPNs. Various roles are integral obligations of the adult 
learner and depicted in this study?s sample.  Thirty-one percent of the sample are 
married; twenty six percent have children; and sixty-two percent work full or part-time. 
The personality profile from the HESI A
2
 showed that the sample represents all four 
types of personalities. 
Grades in the nursing courses of the junior year were analyzed to determine the 
relationship with success in the junior year of the nursing program. Three of the nursing 
courses, Pathophysiology, Holistic Nursing: Adult and Geriatrics and Holistic Nursing: 
Infants and Children showed the highest correlation with success in the junior year. In 
two of the courses, the average semester grade for the group who was not successful in 
the junior year was less than 75. Seventy-five is the lowest accepted grade for 
progression in the program. Both of these courses are taken in the second semester of the 
junior year and are the first of the medical content courses where test questions for 
 97
evaluation of student learning are written at the application or higher cognitive level in 
preparation for the NCLEX-RN. NCLEX-RN questions are mostly written at the 
application level or higher (NCSBN, 2003). Generally, the other junior level nursing 
courses are evaluated with more fundamental knowledge and comprehension cognitive 
level questions.    
In addition to the cumulative score, the HESI A
2
 assesses other aspects of the 
student. Learning styles, personality styles, and behavioral inventory of the students are 
assessed. Each of these components of the HESI A
2
 was analyzed. These additional 
components of the HESI A
2
 may be helpful in identifying students at risk for being 
unsuccessful and out weigh the expense of the administration of the examination. 
Health Education Systems, Inc. provides information on the type of learning style 
of the student. Each student is categorized into two separate groups of learning styles. 
One group includes auditory, cognitive, kinesthetic, and visual learners. The second 
group consists of analytical or global learners. There is no statistically significant 
relationship between the auditory, cognitive, kinesthetic, and visual learning categories of 
the first group of learning styles and success in the first year of the nursing program. A 
majority of students in both the successful and unsuccessful group are kinesthetic 
learners.  
The second group of learning styles consisted of analytical or global learners. 
Analysis of these two groups showed a statistically significant relationship. The students 
who were successful in the junior year of the nursing program were closely divided 
between analytical (49.5%) or global learners (50.5%). A high percent (78%) of the 
students who were not successful in the junior year was global learners.  
 98
The behavioral inventory was to identify students? behaviors and values (HESI, 
2003).  The overall score results indicate how well a student will handle the rigors of 
nursing school (HESI, n.d.b). The results indicated there was no statistically significant 
relationship between the behavioral inventory scores for the students who were 
successful and those who were not successful in the junior year of the nursing program. 
 
Recommendations 
The recommendations from this study encompass two areas: the need for further 
study and suggestions for faculty teaching in nursing education programs. The following 
recommendations address the two areas. 
Recommendations for Further Research 
1. Future research should include the use of additional numbers of 
participants to study the HESI A
2
. Although this study showed a statistically significant 
relationship between the HESI A
2
 cumulative score with the success in the junior year of 
the nursing program, the ability to generalize the results is limited because of the number 
of participates in the sample. This study included 128 participants from one baccalaureate 
school of nursing in the sample. The potential uniqueness of the sample would add to the 
difficulty of generalizing the findings. Additional data from other schools of nursing, 
including associate and baccalaureate nursing education programs, will add to the 
reliability and validity of the instrument.  
2. Studies comparing the HESI A
2
 results of associate degree nursing 
programs with baccalaureate degree nursing programs should follow to determine if the 
 99
HESI A
2
 would have a higher correlation and predictability with one type of education 
program from the other. 
3. Learning styles of nursing students need further study. As shown in this 
study, global learners make up 78% of the group that was not successful in the junior 
year. Further assessment of the students using additional instruments to determine the 
learning style would be valuable in focusing on appropriate methods of teaching. 
4. Selection of criteria for admissions into nursing education programs 
continues to plague faculty. Additional methods of identifying and selecting those 
students who are likely to be successful in the nursing education program should continue 
to determine predictors of success in the nursing education program. Studying individual 
pre-nursing academic support course grades, such as anatomy and physiology or overall 
science GPA as admission criteria would add to the body of knowledge and determine 
consistent predictors of success in nursing education programs (Jeffries & Norton, 2005).  
If the GPA of the pre-nursing academic courses continues to be used as criteria 
for admission into the nursing program, data should support that GPA which has the best 
cut-off point for success. Data from additional classes should be incorporated to further 
validate the use of a particular cut-off point GPA. 
5. The importance of success on the NCLEX-RN impacts nursing graduates 
and nursing education programs. A recommendation for study of the HESI A
2
 and the 
NCLEX-RN results would be beneficial. Identifying factors from the HESI A
2
 which 
predict success or failure on NCLEX-RN will assist nursing education programs in 
identifying students who may be at risk for NCLEX-RN failure. This would determine 
 100
early identification of potential NCLEX failures (Beeson & Kissling, 2001; Higgins, 
2005). 
Recommendations for Nursing Faculty 
1. The GPA of the pre-nursing academic support courses or admission GPA 
was identified as a predictor of success in the nursing education program used in the 
study. Faculty should determine if the admission GPA should be used as a determining 
factor for admission into the nursing education program and what specific GPA makes 
the best cut point for admission. If it is determined that admission GPA should be a 
factor, faculty must further decide if the GPA is the sole criterion or to be used in 
conjunction with other criterion, such as a score on an admission examination.   
2. The HESI A
2
 assessed the learning styles of the sample. Faculty should 
select a variety of teaching methods to accentuate the different learning styles of the 
student population (Forrest, 2004). Nursing faculty are responsible for identifying 
teaching and learning strategies and managing environments that foster the development 
of critical thinking and clinical decisions making skills specific to nursing.   
More specifically, results from this study indicate that students who were not 
successful in the first year of the nursing program were more often global learners. 
Faculty need to explore teaching methods that will enhance learning and applying nursing 
theory content for the global learners (Dunn, 1998).  
3. Demographics and personality profile of the sample in the study validated 
a variety of the characteristics of the adult learner (Long, 2004). Faculty teaching in 
nursing education programs need to be aware of the varied personality, experiential, and 
 101
role characteristics of the adult learner and provide learning strategies in an environment 
conducive to acquiring the knowledge and applying the skills of nursing. 
4. Students who are at risk for being unsuccessful in the nursing education 
program can be assisted and supported by faculty. Faculty should formulate remediation 
strategies throughout the junior and senior year in the nursing curriculum (Beeson & 
Kissling, 2001) or develop a retention program for at risk students (Englemann, 2004; 
Jeffreys, 2004; Lockie & Burke, 1999). 
 
  102
 
 
 
 
 
 
 
 
 
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 116
APPENDICES 
 
 117
APPENDIX A 
 
HESI ADMISSION ASSESSMENT
TM
 (A
2
) 
 
 118
 119
APPENDIX B 
HESI ADMISSION ASSESSMENT (A
2
) FACULTY SCORING GUIDE 
 120
 121
 122
 123
APPENDIX C 
HESI ADMISSION ASSESSMENT (A
2
) SCORING INFORMATION 
 
  
 124
 125
APPENDIX D 
SCORING EXPLANATIONS FOR THE HESI ADMISSION ASSESSMENT (A
2
) 
LEARNING STYLES, BEHAVIORAL INVENTORY, AND PERSONALITY TYPES 
 126
 127
 128
 129
 130
 131
 132
 
 133
 134
APPENDIX E 
INSTITUTIONAL REVIEW BOARD (IRB) SELECTED NURSING EDUCATION 
PROGRAM 
 135
 136
APPENDIX F 
INSTITUTIONAL REVIEW BOARD (IRB) DEGREE GRANTING INSTITUTION 
 
 137