Family Nurse Practitioner Students’ Readiness for Board Certification Utilizing a Full Board Review Course and Simulation

Abstract

Background

The aim of this project was to determine if the implementation of a three-tiered model consisting of a full board review course, round table case analysis, and on call scenarios in the final clinical course of the Family Nurse Practitioner Doctor of Nursing Practice program improved readiness for board certification testing for graduating students.

Methods

An anonymous pre- and post-survey design was utilized. Institutional Review Board (IRB) approval was obtained prior to implementation. A full board review course, including a predictor exit exam component, was utilized in this cohort's final clinical course. Additionally, in-class case review and “on-call” scenarios were facilitated by the faculty to simulate critical decision-making scenarios. A 58% survey response rate was elicited. Prior to the full board review, 16% of respondents felt ready to answer general board-style questions as compared to 100% following the review. Thirty three percent of respondents felt ready to prescribe and provide evidence-based care prior to the project, following the project, 100% of respondents felt ready. Open-ended questions revealed positive feedback for the course and simulated scenarios, however students did feel overwhelmed by the amount of work the course entailed over the course the semester.

Conclusions

Quantitative and Qualitative results indicated positive outcomes and provide support for adoption of the full board review, case-based simulation, and on-call scenarios for all practicum courses at the university. Adjustment of the time requirement and expectations should be reviewed prior to further implementation. In addition, limitations included a small cohort of students in this study; additional studies should be implemented before generalization can occur.

Introduction

In the spring of 2020, clinical placements became nearly impossible due to the global pandemic, as clinical sites prohibited students from completing their clinical hours on site. Universities and students across the country experienced similar situations and the literature is robust in describing the challenges students and faculty faced. The faculty and students at a university in Northeast Florida utilized online modules and virtual simulation to augment students’ didactic coursework during this difficult time. In addition, the clinical placement team worked tirelessly and creatively to achieve students’ minimally required direct patient care hours from various sites over the course of their progression. One cohort of graduate nursing (GN) students, comprised of approximately 17 students, was impacted more severely than others as the bulk of their clinical rotations fell during the shutdown time frame. These students received more online learning than their peer cohorts that were ahead or behind them in their progressions simply due to timing that was out of their control.

To maximize student success for these students greatly impacted by the global pandemic, a full board review course, which was vetted by content expert faculty, was utilized in this cohort's final clinical course in Spring of 2022. Students were guided and mentored throughout the semester with a goal to increase their readiness to test and confidence in providing evidence-based care upon graduation.

Discussion of Topic

The purpose for implementing a Family Nurse Practitioner (FNP) certification review course came from our students’ acute need and studies that support using competency-building components required from National Organization of Nurse Practitioners Faculties guidelines for clinical and didactic classroom environments with an enhancement of self-directed learning tools (Wilson et al., 2015). The literature is robust in supporting the use of board review courses to help prepare graduating students to take their certification exams and the consensus to provide simulated, on-call scenarios for nurse practitioner students and the value these experiences provide in preparing these students for practice.

The use of standardized testing with review modules in nursing programs has been studied extensively for outcomes on National Council Licensure Examination exams (Homard, 2013; Kaddoura et al., 2017). Accrediting agencies such as American Nurse Credentialing Center and American Association of Nurse Practitioners require a minimum score on certification exams for first-time licensure. The goal of most NP programs is to ensure readiness for the board examinations in hopes of achieving a nearly 100% pass rate. The current university utilized a board preparation review course that claimed a 99% pass rate after the course completion.

The aim of this project was to determine if the implementation of a full board review course in the final clinical course of the FNP program improved readiness to test for graduating FNP students. Additionally, faculty aimed to increase confidence to provide evidence-based care for graduating FNP students by supplementing the full board review course with case based round table scenarios and on-call live simulations facilitated by faculty acting as live actors.

This University's nursing program is comprised of approximately 329 GN students across NP and non-NP cognates. Within this GN cognate where the interventions were implemented, 36% identify as a minority and 9.23% as male.

Clinical partnerships and placements contribute greatly to the rich education students receive at our university, as point of care learning is paramount for optimal preparation for the NP. During the pandemic, clinical placements became obsolete with shutdowns persisting for nearly one calendar year. NP students were provided online learning and virtual simulation opportunities to augment their didact course work. Students demonstrated an incredible amount of flexibility, resilience, and willingness to change as they adjusted to the adversity they faced.

One cognate in particular was greatly affected by the global pandemic—the Bachelor's of Science in Nursing (BSN) to Doctor of Nursing Practice (DNP) FNP students who were slated to graduate in the spring of 2022. Due to the vast clinical shutdowns and timing of their progressions, these students experienced more online learning than other cohorts. As such, faculty felt it necessary to provide equity in education for these students prior to their launch into the community. Clinical preparation and readiness for national board exams ensures students are properly prepared to engage in, lead, and strengthen the NP profession while collaborating within the healthcare team. To promote this readiness, with generous funding from the university through the Office of Research and Sponsored Programs internal Department of Education EPIC program, a full board review course was provided at no cost to these students in their final semester.

Methods

The university IRB reviewed the project and determined the project to be exempt. Students who participated in this project were voluntarily enrolled in one course section and participation in this survey did not impact their grade. The surveys were submitted through Qualtrics, and all data obtained was secured in the university cloud-based server, accessible only to the researchers. Informed consent was included on the survey and completion by the student implied consent. To reduce the risk for coercion, the Primary Investigator that sent recruitment information was not faculty teaching the course. The survey was optional, and students were given the choice to opt out of survey completion. Data from the surveys were not evaluated until after the semester concluded. Course faculty were not aware who participated in the survey as data was only reported in the aggregate form. However, whether students chose to participate in the survey or not, they were required to complete the intervention for course success. The pre-survey was administered on day one of class and on the final day of class, students completed the post-survey. Provided positive results were obtained, the goal was to incorporate this into all NP practicum courses (Figures 1 and 2).

Figure 1.

Pre-survey.

Figure 2.

Post-survey.

The faculty conducting the project collaborated to organize an interactive, case-based course with the integration of the full board review course. As students had already completed the required hours for board certification eligibility, further direct patient care hours were not mandated, though students could elect to pursue hours in addition to the review course and class meetings. Students were required to attend four, three-hour live sessions throughout the term. Prior to the meetings, students were asked for input on topics they would like to review. Course faculty then prepared material to include micro-lessons and interactive case studies on the various topics requested for review and round table discussion during class.

As a provider readiness exercise, students were also required to sign up for two days of on-call time where course faculty would call students and simulate a variety of patient scenarios that necessitated NP evaluation and decision-making. Once decisions were rendered by the student, faculty would provide feedback on the evaluation process and decisions made. Out of respect for outside employment and work-school-life balance, students were only called during business hours and each student received at least two calls each day of their on-call time frame.

Lastly, students were provided online access and a schedule of topics for the board review. Beginning with a pretest, students were permitted to complete the modules and section quizzes independently but were encouraged to keep pace with the schedule to complete the full review within the semester. Each week, an online learning manager from the board review company would email course faculty an updated report on completed module quizzes and the student's outcome. Once all modules were reviewed, a post-test was completed. In addition, a 150-question, timed predictor exit exam was completed for further board practice.

Measures and Analysis

Because no instrument to evaluate outcomes of this experience was identified, faculty members developed a survey through an iterative process by formatting questions according to similar tools and faculty consultation. The tool was validated by three panel experts that teach in the NP program using an expert panel validation rubric (Carmines & Zeller, 1991). The pre-survey consisted of a six-item instrument with two open-ended questions asking for student goals for the class and what they hoped to achieve. This helped guide the round table discussions and for faculty to gear the diagnostic reasoning cases around these patient populations. The post-survey included the same six Likert scale questions and five open-ended questions: “What went well?”; “What could be improved or changed?”; “What went well with the review course?”; “Was the review course beneficial and why?”; “General comments and suggestions for the future.”

To ensure anonymity of the data collected, survey settings were manually reconfigured to Anonymize Response. This setting prevented Qualtrics from collecting data such as IP addresses and email addresses. Students also created a personal code using the following algorithm: First letter of a favorite fruit (e.g., Apple); Last 2-digits of your cell number (e.g., XXX-XXX-XX41); Month you were born using a numerical format (e.g., September = 09); Two letter city you were born (e.g., San Juan = SA). This also allowed pairing of pre- and post-survey results.

A convenience sample of 17 students participated in the project. A power analysis was not used. Pre- and post-test survey results were evaluated utilizing Qualtrics XM provided by the University. Data were matched based on the participants’ own code created to ensure anonymity. For the open-ended questions, qualitative methodology was used to identify emerging and/or reoccurring themes. General themes identified through thematic synthesis (Thomas & Harden, 2008) included: “benefit of having a full board review course at the end of the program”; “overwhelmed feeling with the amount of work the review course entailed”; “thankful for the opportunity to have this as a supplement to their education.”

A 58% response rate was elicited. Prior to the full board review, 16% of respondents felt ready to answer general board-style questions as compared to 100% following the review course and simulated case scenarios. Prior to the project, 33% of students reported readiness to safely prescribe and provide evidence-based care. Following the project, 100% of students reported readiness to prescribe and provide evidence-based care. Students who chose to also complete direct patient care clinical reported difficulty completing the course in addition to their clinical work. However, for those that only completed the review course and case-based simulations, the time commitment was manageable. The overall findings for the specific review course were positive and support to incorporate with other cohorts was recommended by the students.

There were marked limitations to this study including only one cohort of students in one private institution with a small sample size of 17 participants. The timeline was limited to 15 weeks due to the semester calendar. Considerations for implementing a certification review course include having additional review time in class and/or requiring more live sessions, grading modules to improve motivation, and/or insertion in a curriculum that does not compete with a high stakes course. Prior to any generalized conclusions being reported, more studies with similar interventions should be conducted.

Conclusion and the Importance to Nursing Profession

This project provided a practical three-tiered model that could be replicated in other institutions. This model includes a full board review course incorporated into the final course of the curriculum, coupled with case-based round table discussions, and simulated on-call scenarios. Together, these interventions improved perception of readiness for board certification and practice among our students. Our findings were consistent with previous simulation studies in which students reported feeling more prepared to provide evidence-based care and more ready to take their certification exam upon graduation (Conelius et al., 2019; Dumphy et al., 2019; Finneran & Kreye, 2021). If costs were a barrier for an institution, replication projects could center around solely using case-based diagnostic reasoning sessions and on-call scenarios to gauge readiness for practice. The faculty participating in this project had varying clinical expertise including adult, pediatrics, family, and psych-mental health thereby contributing to the variety and depth of the clinical scenarios written and used in the project. This added value to our overall project but is not necessary for replication.

The intervention was utilized as a board review and students were not graded on scores or effort. Low-stake testing relies on motivation of the examinees and if little effort is exerted, the validity of the test scores is skewed (Wise, 2006). Numerous studies conducted by Wise (2006) found that test-taking efforts improved when test results correlated with something the examinee needed such as a grade, diploma, licensure, etc. This board preparation course was implemented during a semester that also included a didactic course in pathophysiology. Implementing this course review along with a demanding, high-stakes didactic course, overshadowed the low-stake review course. Studies have found that the validity of low-stakes exams directly correlates to poor examinee effort, which can alter the validity of the test (Wise, 2006).

Nurse practitioners are integral in the healthcare field and are relied heavily on to provide safe, evidence-based care. Students in NP programs rely on clinical rotations to augment their didact education in preparation for entry into the field (Conelius et al., 2019; Dumphy et al., 2019; Finneran & Kreye, 2021). When clinical placements were greatly affected by the pandemic, universities were called to provide alternate ways for students to become prepared to enter the healthcare field with confidence and readiness. The model we utilized for our at-risk student group proved to be positively received by students and beneficial to their preparation and readiness to test and provide safe, evidence-based care.