by Jennifer Hooper, RN BScN, MN

Citation: Hooper, J. (2022). Mode Matters! Undergraduate Nursing Students’ Perceptions of Test-Preparation and Test-Taking Strategies for Computer Based Testing. Canadian Journal of Nursing Informatics, 17(1).  https://cjni.net/journal/?p=9759

Abstract

Background: Until recently, computer-based testing (CBT) has not been widely used in Canadian nursing programs and traditional paper-based testing has been the predominant testing modality. However, since the COVID-19 pandemic, many nursing schools very quickly adapted to remote evaluation strategies including rapid CBT implementation. There is limited literature surrounding how nursing students prepare for and what test-taking strategies are used when completing CBTs as opposed to traditional paper-based exams.

Purpose: The purpose of this study was to gain an understanding of undergraduate nursing students’ perceptions of test-preparation and test-taking strategies specific to CBT. Sharing this knowledge may contribute to the body of literature and serve as a foundation for further research.

Method: Through purposive sampling, this qualitative study was implemented, and data collected using online surveys and semi-structured focus groups.  Data was analyzed by thematic analysis.

Results: Three themes were generated: double duty, test-taking tribulations, and repeat exposure. Findings including test-preparation learnings, test-taking challenges, and recommendations for CBT are discussed.

Conclusion: CBT poses both challenges and learning opportunities for students. Exposing students to CBT may increase their awareness of effective test-preparation and test-taking strategies which may positively contribute to how they prepare for future computerized exams.

Introduction

Canadian nursing educators have dedicated much attention to the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Educators strive to provide undergraduate nursing students with adequate preparation to achieve success on this licensure exam that grants eligibility for registered nurse (RN) practice. Prior to 2015, the Canadian licensure exam was a paper-based exam. In 2015 the NCLEX-RN was adopted by most Canadian regulatory jurisdictions in part for its computer adaptive format (Canadian Nurses Association [CNA], 2015a). The NCLEX-RN differs from the former Canadian licensure exam in using a computerized delivery mode, the content that is tested and the use of alternate format styles of questions (AFQs). AFQs are different than standard multiple-choice questions and may include multiple response (single, multiple or all responses could be chosen), fill-in-the-blank (calculation questions), ordered response (requiring the candidate to identify correct sequencing) and graphic hot spot items (presents images requiring clicking on a correct location usually used in nursing (NCSBN, n.d-a). Upon initial implementation of the NCLEX-RN, Canadian pass rates declined by over 10% and up to 40% compared to previous pass rates (CNA, 2015b). Canadian nursing schools have responded by implementing approaches to more effectively prepare students for this exam. Increasing student exposure to higher-level questions, AFQs and computerized modes of delivery are some of the suggested methods (Canadian Association of Schools of Nursing [CASN], 2014; Dosch, 2012; Okunji & Hill, 2014, Pawasauskas, et al., 2014).

Until recently, computer-based testing (CBT) has not been widely used in Canadian nursing programs and traditional paper-based testing has been the predominant testing modality. Since the COVID-19 pandemic in 2020, many nursing schools rapidly adapted to remote evaluation strategies some of which included the implementation of CBT. Educators should implement successful preparation strategies into undergraduate programs, and collect data regarding these strategies to better prepare students for successful NCLEX-RN completion. While empirical evidence (strategies and pass rates) is important, student perceptions of interventions are also crucial (Quinn, et. al., 2018). There is limited literature that focuses on student experiences with CBT in Canadian undergraduate nursing programs. Furthermore, there is little evidence that addresses how students prepare for computerized exams or apply test-taking strategies.

Background

In a four-year University Bachelor of Nursing program, strategies have been implemented to prepare students for the NCLEX-RN including preparatory modules, assignments and incorporation of alternate format questions on tests. However, the testing mode has largely remained paper-based. In 2018, I converted all paper-based exams to CBT in the compulsory third year maternal newborn nursing course via Blackboard©, the university’s learning management system. In this course, students are exposed to CBT on four occasions: two ungraded practice quizzes, a graded midterm and a graded final exam. In 2019, I completed qualitative research to gain an understanding of student general experiences and perceptions of CBT given it had been their first exposure to graded CBT approaches in the nursing program. Data was obtained by collecting and thematically analyzing anonymous sets of reflective questions (n= 38). While general advantages and disadvantages were identified, one striking topic area that emerged from this research was student learning that a new mode of testing (computerized) requires the need to learn new test-taking strategies as strategies for paper-based exams (e.g., circling, highlighting, underlining, crossing out answers) cannot be transferred (Hooper, 2020). These prior findings led to the development of this current study specifically examining test-preparation and test-taking strategies.

Aim

The aim of this qualitative study was to gain an understanding of undergraduate nursing students’ perceptions of test-preparation and test-taking strategies specific to CBT. Not only are the goals to inform personal teaching practices but to share knowledge with other educators who may be considering or are already using CBT in their courses. It may benefit educators to comprehend the unique challenges specific to CBT and consider strategies to support students with this mode of testing. Sharing this knowledge may contribute to the body of literature and serve as a foundation on which further research could be conducted.

Methods

Qualitative research methods were used and data was collected from two types of sources: anonymous online surveys and semi-structured focus groups; both voluntary. The maternal newborn six-week course runs five separate times per academic year. For this study, data was collected from three of the five cohorts. The purpose of this study was to gain an understanding of third year undergraduate nursing student perceptions of test-preparation and test-taking strategies specific to CBT. The research was guided by the following questions:

What strategies did students use to prepare for CBT?

What did students learn about their test-preparation and test-taking strategies for CBT?

What would students do differently in the future when preparing for and completing CBT?

I, researcher and author, was on a sabbatical leave during the time of data collection and did not hold any teaching or supervisory relationships with the students at this time. This was deemed to mitigate any potential or perceived conflict of interest. An ethics application for the study was submitted and approved by the Mount Royal University’s human research ethics board prior to conducting the study. I have no product (commercial or proprietary) interest, potential conflicts of interest, financial or otherwise to disclose.

Data Collection

Through purposive sampling, data was collected from three cohorts of students that completed the maternal newborn course in the Winter and Spring 2020 semesters. After course completion, an overview of the study and a link to the online survey and electronic consent form was posted on the student Blackboard© course site. At the end of the survey there was an invitation to participate in a subsequent focus group. Additionally, on the course Blackboard© site, an overview and invitation specifically for the focus group was posted to provide opportunity for students who wanted to participate in the focus group only and not the survey.

From the three cohorts (approximately 90 students), there were 35 participants in the online surveys and seven participants in the focus groups. The survey and focus group results provided similar data and all responses were included in the analysis. The survey was administered via Google Suite©; the university’s designated platform and consisted of eight reflective questions. The students who volunteered for the focus group were provided a separate consent form which included statements and agreements surrounding confidentiality of the researcher and participants. The focus groups were facilitated at a mutually convenient time via Google Meets© and a series of semi structured questions were posed. There were two focus groups (n=4 and n=3) and each ranged between 30-40 minutes in duration. Audio only was recorded using Audacity©. After completion, the audio recordings were sent to a professional transcriptionist.

Data Analysis

Data from the surveys and transcribed focus groups was collected and then analyzed by thematic analysis. This was performed in an extensive three phased process: 1) Reading for resonance: familiarizing oneself with the content 2) Coding: identifying key words, phrases, and passages of text that are meaningful to the research question and 3) Categorization into themes: inductive codes are reviewed and subsequent themes are generated (Jirojwong, et al., 2014). In qualitative research it is crucial that the researcher evidences their methodical, exhaustive and rigorous process to produce meaningful results. This can be achieved when the researcher discloses a detailed method of data analysis (Nowell et. al., 2017).

The survey and focus group data sets were initially read separately before comparison. Reading and re-reading the written responses to the surveys first occurred. This extensive familiarization process, revisiting the survey data, and continuous return to the research question led to the generation of initial codes. This same process was then applied to the focus group data. The data from the surveys and focus groups were then collectively reread. Once the data was initially coded from the surveys and focus groups, a list of common codes across the data sets was created. Furthermore, during this coding process, labels were applied to categorize codes as they related to emerging themes in the data. These inductive codes were then categorized leading to the development of initial themes. The researcher returned to the raw data again and compared and contrasted the concepts, codes, and initial themes identified in both the survey and focus group data. A reflexive journal was kept throughout the research process as one of the methods to enhance trustworthiness of the research. The initial themes were extensively reviewed and reflected upon in relation to the research question and the final three themes were generated.

Results

Double duty, test-taking tribulations, and repeat exposure were the three main themes produced.

Double Duty: In terms of preparing for the tests, students believed that because the content they were expected to know would be the same regardless of the testing mode, they used the same preparation approaches for CBT as they did in prior courses when preparing for paper-based tests. One student said:

“the exams are testing the same material… computer and paper-based tests requires you to have the same amount of knowledge on the material.”

The identified preparation approaches included the use of flash cards, reviewing class notes, re-reading the text book, and studying in groups. What they identified as different however, was in addition to content preparation, they had the added burden and workload of preparingfor the exams’ delivery mode which included doing an increased number of NCLEX-RN alternate style practice questions and online practice quizzes before the graded exams. One student said:

“Shifting my studying habits to a more virtual format, like, taking practice tests online vs a huge book full of practice questions… just gaining more familiarity around the virtual testing system… we’ve been doing paper tests for so long it became second nature so now getting thrown into a virtual testing system is different.”

Also, within this theme of double duty, students expressed their perception of the educator’s responsibility to help students prepare for the mode. They perceived that currently the onus is on the student to learn these new strategies. One student said:

“… how they prepared us to highlight and underline…and now we didn’t have those strategies, it was a very different way of learning to take the exam”. I think I would need to start doing more research into preparing ways for CBT other than the methods I have now”.

While content preparation strategies were deemed unchanged, the students clearly perceived delivery mode preparation as a separate entity and independent of content preparation. Students revealed new learning in that how they prepared for CBTs was impacted by the testing mode. They identified that some of the preparation strategies that they used in this course differed compared to prior courses where paper-based exams were the predominant approach. One student stated:

“I did more NCLEX types of questions…and more online practice questions than I usually do in other courses.”.

When it came to actually completing the midterm and the final exam, students identified that test-taking strategies was an area of stress which led to the subsequent theme.

Test-Taking Tribulations: Students perceived challenges with not being able to transfer previously learned test-taking strategies for paper-based exams (e.g., circling, highlighting or underlining important information, crossing out answers or writing notes on the exam itself), to CBT. One student stated:

“It impacts the approach I use when completing the test because of the online format- I am used to writing all over the page”.

Another test-taking challenge identified by students were the test administration functions that were used for these CBTs. Blackboard© has many test administration options including the ability to randomize questions for each student and present questions one at a time on the screen; both of which were used for the CBTs in this course.  An additional function used was prohibited backtracking; once students submitted an answer to a specific question they could not return to the question. In this research study, students perceived this to be an extremely challenging and stressful experience. One student described their experience:

“I found it difficult that I was not able to go back and review my previously answered questions. I never write exams in the order they are given to me as I do the questions that I can answer easily first… since we weren’t able to go back, I wasn’t able to move ahead if I was stuck on a question and come back to it… you basically had to know everything at all times. This was a challenge.”

Another student described a similar perspective:

“… if I’m uncertain about a question I will skip it and come back at the end so this computer system was very different for me… so maybe it is a good idea to try and write a test from start to finish and not skip around so much so that is definitely something I am trying to implement and make an adjustment before NCLEX next year”.

While students deemed this to be a tribulation, they also perceived it as a future preparatory benefit as the NCLEX-RN also presents questions one at a time without the ability to revisit a previously answered question.One student described the benefit this way:

“It gave me an idea of what NCLEX would look like in relation to taking the test and not being able to go back to a specific question…CBTs have helped me adjust my test writing skills to the NCLEX format…I believe it was valuable to have computer-based exams this semester.  I will be practicing more NCLEX style tests in the future to prepare”.

Learning that CBT requires different exam navigation and test-taking strategies uncovered students’ desire to have increased opportunities to develop and implement the same. This led to the final theme.

Repeat Exposure: While students experienced test-taking tribulations, they also perceived direct benefit and their desire for increased exposure to CBT approaches. One student said:

“I definitely believe these computerized tests should be used for all nursing courses. It allowed me to get a sense of how the NCLEX exam would be and I felt less anxious completing the second (final) exam [after the midterm]. …I think if it [CBT] was implemented earlier on in the program then I would have more time to adjust. The format of the NCLEX can be intimidating so it’s good to get as much practice for it as possible”.

Students identified perceived benefits of not only having an increased number of courses offer CBT, but to have it implemented early on in their nursing program to increase the amount of practice opportunities.

Discussion

Many educators are curious about how students prepare for their exams. Effective versus ineffective preparation strategies are well documented and the literature describes both effective (e.g., flash-cards and practice tests) and ineffective (e.g., re-reading course textbooks and class notes) approaches. However, students tend to underuse practice tests and place too much emphasis on re-reading (Blasiman, et al., 2017; Janes, et al., 2018; Morehead, et al., 2015). While substantive literature exists regarding effective test-preparation strategies in general, there is little emerging yet that specifically targets those for CBT. In this study students perceived that they had to ‘know’ the content regardless of how it was being tested. When preparing for the content, students stated they used strategies similar to those identified throughout the literature including practice tests, group study sessions, use of flash cards, re-reading course notes, and re-reading the textbook. These examples exhibit a combination of both effective and ineffective approaches. However, students appear to be unaware of the importance of effective strategies, as many indicated using more of those that are considered ineffective.

Interestingly, in this research study, students perceived a distinct difference between ‘content preparation’ and ‘mode preparation’. For mode preparation, they indicated they practiced using online quizzes “significantly” more in this course compared to other courses where paper-based tests were the predominant approach. Students also revealed their perception that the educator role should include supporting student preparation for both content and the mode. This finding is consistent with other studies that have examined student perceptions of support for NCLEX-RN preparation. In a study by Logue & Gordon (2018), students stated that faculty should revise curriculum to better align with the content and style of questions on the NCLEX-RN and that it was the faculty and programs’ obligation to better prepare students for this licensure exam.

While CBT advantages include immediate exam scoring, reduced scoring errors, effective use of large question banks, reduced cost and time, potential for adaptive testing, and enhanced analysis of individual student performance (Bloom et al., 2018), disadvantages also exist. Disadvantages include increased student anxiety levels attributed to perceived risk of having technical problems and inability to write on the exam itself (Bloom, et al., 2018; Vrabel, 2004).

In this study, the students’ comments reflected many of the advantages and disadvantages as noted in the literature. Students indicated their desire to have more online practice quizzes and have CBTs implemented earlier on in the program. Some students ventured to say that all nursing courses should integrate CBT to increase exposure to the delivery mode. Major disadvantages perceived by students surrounded a loss of their previously learned test-taking strategies (e.g., crossing out, underlining, highlighting) and the inability to return to a previous question once answered. Exam navigation was a code embedded within the theme of test-taking tribulations. They indicated that in previous paper-based testing experiences, they would use a variety of navigation strategies to answer more difficult questions including using other exam questions to ‘trigger’ their memory for a previously answered question. Student anxiety surrounding CBT has been well documented in the literature. This anxiety can be decreased by providing repeated opportunities for students to experience the mode of testing. Faculty should familiarize students with and repeatedly use the same technology when administering quizzes and exams throughout the course (Kolagari, et. al., 2018).

Within the theme of test-taking tribulations and code of exam navigation, the concepts of ‘confidence’ and ‘time management’ were evident. Students consistently stated that not being able to go back to a question resulted in spending too much time on difficult questions and time management became a concern. One student identified that one of their strategies going forward may be to increase the amount of time studying for the content leading to increased knowledge and confidence in answer selection resulting in improved time management during the exam. Increased studying using effective studying strategies and time management are key concepts that educators should emphasize for students. While this study did not capture data specific to how much time students spent on content versus mode preparation, this finding was repeatedly alluded to throughout the data and one that may be of interest to further investigate in a future study.

Recommendations

Regarding content preparation, educators should consider ways to increase student awareness of effective versus ineffective studying strategies and encourage the development and use of those strategies that are known to be more effective. This could be achieved through highlighting the importance of the same in course orientation or through providing a tutorial on this topic area. Regarding preparation for the mode, educators should acknowledge the loss of students’ previously learned exam navigation strategies and respond by teaching ways to prepare specifically for CBTs. This may be particularly important when students are completing CBTs that have the test functions enacted of presenting one question at a time and where backtracking is prohibited. This is significant considering that the NCLEX-RN presents questions in this same manner. Promoting student learning and development of new test-taking skill sets could be achieved by educators integrating ungraded practice quizzes into courses that have these test functions enabled. This may increase student exposure to these test nuances in a low-stakes setting.This could in turn build student confidence and decrease anxiety levels. Furthermore, implementing practice and graded CBTs early on in the program should be considered where feasible.

Extending beyond the nursing program, an additional consideration to support these types of initiatives may be to collaborate with the university’s student learning center and faculty academic development centre. For students, accessing the university student learning centre to gain tips for completing CBTs could be useful. For institutions that have a faculty academic development centre, it could be beneficial to provide best practice workshops for educators that may be new to integrating CBT into their courses. This may equip educators with resources that support successful integration of this testing approach.

There are various commercial products available that nursing schools can integrate into their undergraduate programs that have been positively linked to increased rates of NCLEX-RN success (e.g., Health Education Systems Inc., PassPoint, UWorld). These products however carry a cost and financial impacts on students should be considered(Logue & Gordon, 2018; McGillis Hall et. al., 2016). If commercial products are deemed to support NCLEX-RN success, educators should engage in discussions with leadership about the potential for programs to absorb these costs. Increased discussion between leadership, faculty and students may enhance understanding and expectation of roles, responsibilities, and opportunities to collaborate and integrate products where feasible.

While not one of the main foci of this article, an additional recommendation is that nursing educators be aware of the National Council of State Boards of Nursing’s (NCSBN) planned implementation of the 2023 ‘Next Generation NCLEX’ (NGN). The types of questions that will be asked on the NGN will be different than the current NCLEX-RN. There will be a decreased focus on content and increased emphasis on clinical judgement to reflect the kinds of critical decisions nurses have to make in various healthcare settings. The NGN exam will achieve this by using new styles of questions including complex case studies, extended multiple response, extended drag and drop response, enhanced hot spot, and matrix/grids (NCSBN, n.d-a). Nurse educators should challenge themselves to be familiar with this shift and revise curricula and teaching approaches to better equip students for the complex critical thinking and clinical judgement required for the NGN. This may be achieved by providing frameworks and detailed approaches that show students ‘how’ to critically think at all levels of nursing education (Caputi, 2019). While teaching students how to critically think may better support students in the NGN, I would also recommend that nursing educators integrate these new styles of questions into course exams.

As the licensure exam design is likely to evolve as evidenced with the upcoming NGN, one recommendation would be that undergraduate programs have a committee dedicated solely to licensure exam related items. Committee members should include faculty members who are well-versed in licensure exam test plans, exam design, and knowledge transfer. Facilitating professional development activities may provide ongoing support for faculty who are eager to incorporate these teaching and examination approaches into undergraduate courses. Exposing students to these styles of questions in undergraduate programs may increase students’ test-taking confidence before the high stakes NGN exam while also enhancing student clinical preparation for practice upon graduation.

In this study while there were many challenges perceived by students that included the added responsibility of preparing for the testing mode and needing to learn new test-taking strategies, students did appear to perceive overall benefit. One student said:

“Though they are not the easiest exams to write, they do help us to prepare for our NCLEX exam which is arguably the most important exam of our nursing career. I think CBT was beneficial for me to learn what my NCLEX exam would look like. It definitely makes me more prepared for the NCLEX”.

The findings are such that this author is dedicated to continued CBT approaches to enhance student development of effective test-preparation and test-taking strategies. This author has developed case studies with integrated CBT practice questions as a teaching-learning strategy in the classroom setting. Additionally, this author is currently engaged in a program-wide initiative to support faculty with the same. This three-part series has begun with an introduction to upcoming NGN licensure exam changes. Upcoming interactive workshops will be focused on integrating clinical judgement and NGN approaches into classroom, clinical and simulation settings and the integration of exam questions on course exams. It is this author’s intent to collaborate with other educators, nursing and beyond, to develop best practice approaches to better prepare students for future CBTs.

Limitations

A limitation of this study includes the small sample size (online survey n=35; focus group n=7) and that the data gained from this purposive sample reflects only those perceptions of three cohorts of students that completed the maternal newborn undergraduate nursing course. Also, as with any self-reported data, bias may contribute to findings. While these findings are not transferrable, it may be beneficial for educators to gain an increased awareness of the unique challenges specific to CBT and acquire new knowledge that promotes the integration of supportive strategies for students.

Conclusions

Nursing educators must continue to consider, implement, and evaluate appropriate strategies to support students in CBT, NCLEX-RN and future NGN preparation. This may include increasing the number of online practice tests, integrating CBTs early on in the undergraduate nursing program and increasing student awareness of the need to develop a new skill set when preparing for CBTs in light of delivery mode and question presentation. Providing these opportunities may encourage students to reflect on their test-preparation and test-taking strategies promoting confidence in how they prepare for and engage in future computerized exams.

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AUTHOR BIOGRAPHY

Jennifer Hooper, RN BScN, MN

Jennifer has completed her undergraduate Bachelor of Science in Nursing degree through St. Francis Xavier University in Nova Scotia and her graduate Master of Nursing degree at University of Calgary in Alberta. She is an Associate Professor at Mount Royal University who teaches across the Bachelor of Nursing program as well as in the Bridge to Canadian Nursing program. She has a strong clinical focus in maternal-newborn nursing and continues to practice in this setting alongside her educator role. Jennifer is actively involved in the Institute for the Scholarship of Teaching and Learning and one of her key research and scholarly pursuits surrounds higher education and supporting student learning and transitioning to practice.