The Clinical Performance in Nursing Exam (CPNE): what the heck is this madness?!

**Lunah**, MSN, RN

So what is this exam?

The CPNE is a rigorous 2.5-day exam consisting of four timed lab stations on the first night (Friday), then a minimum of three Patient Care Scenarios (PCSs) on Saturday and Sunday, during which masters- or doctorate-prepared nurses evaluate our ability to formulate care plans, carry out assigned areas of care, and evaluate and document everything in a total of 2.5 hours using actual hospitalized patients who have agreed to have student nurses. The Clinical Associate (CA) oversees the testing and is in charge of the Clinical Examiners (CEs) who oversee the students. We are assigned a minimum of two adult patients and one pediatric patient for the PCSs, though some hospitals with a low pediatric census may substitute an adult patient for the pediatric patient (but don't count on this!). During the CPNE weekend you can fail and repeat each lab station once, as well as fail and repeat one adult and one pediatric PCS.

Where do you go to take the CPNE?

Excelsior's CPNE test sites are located in hospitals in Georgia, New York, Pennsylvania, Ohio, Wisconsin, and Texas. Generally speaking, students who apply to test at the NY sites seem to get a date the fastest, and this is likely because there are more sites in NY than anywhere else.

The sites are split up between regions, into what they call RPACs-regional performance assessment centers. The Midwestern Performance Assessment Center (MPAC) includes Wisconsin and Texas (three sites total). The Northern Performance Assessment Center (NPAC) is the NY and Pennsylvania sites (six sites total). Finally the Southern Performance Assessment Center (SPAC) oversees the Georgia sites (four sites total, one of which doesn't hold the CPNE every weekend). You can only apply to test in one RPAC at a time, but you can apply to test at multiple sites within each RPAC. If there's one particular site you want, you can choose only that location, but with the realization that it might slow you down in terms of getting a date.

I applied to the one Ohio site-Mansfield-because it was within driving distance for me. I didn't take a cancellation date, so it took me about seven months from application to actually being at my CPNE. I needed that time, though-I used it to finish Micro and two CLEPs, then to study for the CPNE. Mansfield closed as a site a few years ago.

Enrolled students with a login can access information on all the CPNE sites: Excelsior College

Just a personal take on "which site is the best"-first, whether a person passes or fails at a site is seriously going to color his/her perception of the site. How could it not? This is an intense exam that usually requires life-consuming focus for preparation, and when someone pours that much into an endeavor that isn't successful, there is bound to be some negativity. My advice: pick a site and focus on YOUR preparation. Don't listen to the reasons Fred chose Utica, or the reasons Mary won't go to Wisconsin. I can tell that during my time around Excelsior students on various message boards, I've seen some sites go from being evil pits of despair to being the golden ticket, then back again. For every site, you will hear both good and bad, usually depending on how a student fared there. When I arrived at my CPNE site, I merrily logged on to the old EC electronic peer network (EPN) to let people know I'd arrived safely and was ready to go get that GN. One of the first posts I saw was from someone bashing Mansfield because they'd failed there the previous weekend; the post said the CA and CEs were horrible, the site was unfair, no one would ever pass there, and on and on. I thought I might vomit. But I knew that I was going to be successful because I would allow no other option, no other thinking. So yes, maybe people should stay off of websites around the time of the CPNE, but the EPN and Allnurses were big support systems for me, and I needed that more than I needed to NOT read angry spewing about my site (where I was, indeed, successful on my first CPNE attempt).

The flow of the exam

That first evening are the four lab timed stations: calculating and administering an IM or SQ injection (you'll get one or the other, you don't know which), calculating and performing an IV push, IV piggyback (calculating and setting a gravity drip), and packing a wound with perfect aseptic technique. If you fail any of these lab stations, you can repeat them one time (before being sent home with a failure) the next day, after you take care of your patients for your first PCSs.

The length of each day depends on how you do. For the labs, we met in the hospital lobby at 1615 on Friday and were done by about 2000, and there were five of us testing. There is some administrative blah-blah-blah before the labs, including positively identifying the students (bring your ID!) and reading the students the mandatory EC script.

For days 2 and 3, you'll have a max of two PCSs on Saturday and a max of three on Sunday (but at least one). On Saturday, you'll also have the opportunity to repeat any labs you may have failed, which is done after the Saturday PCSs. Depending on the number of labs, you might be there late into the afternoon. Sunday you can get out pretty early if you don't have to repeat a PCS. If you end up having to do more than one PCS on Sunday, you can bet you'll be there until late afternoon.

Wait, what?

I know that the PCS failure thing can get kind of confusing, as can the mix of people who make it to Sunday and those who don't, or those who have to do five PCSs to pass, that kind of thing. Let me give you a couple of scenarios.

Frankie is assigned an adult PCS and a pediatric PCS on Saturday. He fails both. Can he come back Sunday and still pass? Yes! But he will have to pass two adult PCSs and one pediatric PCS on Sunday, for a total of five PCS attempts. He just used up his adult and pediatric fails on Saturday, that's all. I have seen people do this and still emerge victorious!

Charlie is assigned two adult PCSs on Saturday. He fails both. Can he come back Sunday and still pass? No! He used up both adult chances on Saturday, leaving him with no more opportunities to pass an adult PCS. He goes home Saturday.

Natalia is assigned two adult PCSs on Saturday. She passes both. She then fails her IVP lab repeat because she throws her syringe in the trash instead of the sharps container. Can she come back Sunday and still pass? No, because she failed her repeat lab. She goes home Saturday.

So what's the big deal?

The CPNE isn't really a test of skills; it is basic nursing assessment and basic management. Nothing too fancy! They want to see that you can provide safe care to patients. The entire nature of the program is predicated on the students being healthcare providers already, or having gone through more than 50% of a traditional nursing program's clinicals. Beyond writing careplans, there really wasn't much foreign material for me at the CPNE, and I came into the program as a paramedic.

For the PCSs, as stated, you must pass two adult and one pediatric PCS. For each PCS, you have 2.5 hours to formulate a careplan with two nursing diagnoses, carry out your selected interventions related to your careplan goals while also performing selected and required areas of care, and then documenting the whole thing without missing a critical element. You are not asked to do anything terribly invasive. It's a test of basic concepts like time management and prioritization. Your patient isn't in a bubble during those 2.5 hours-docs will come in, family members, PT/OT, x-ray, etc., so time management really is a factor.

Overriding and required areas of care include demonstrating caring, ensuring physical safety at all times, not placing the patient in emotional jeopardy, evaluating mobility, checking a set of vitals to include manual BPs that must be within a few points of what the clinical examiner gets (you're using a double-headed teaching stethoscope for BPs, apical pulses, lung sounds, etc.), and fluid management (checking IV sites, infusing fluids, etc.).

Assigned areas of care (most students get 3 or 4 of these assigned) include things like peripheral vascular assessments, neuro assessments, abdominal assessments, respiratory assessments, respiratory management, O2 management, comfort management, pain management, skin assessment, musculoskeletal management, specimen collection, irrigation, enteral feeding, wound management, medication management, and patient teaching. After all that, everything has to be documented perfectly, and students evaluate the effectiveness of their careplans in writing and choose a priority nursing diagnosis, supported by a rationale.

As I said, you can fail one adult PCS and one pediatric PCS, and repeat those once each before you're sent home without that coveted "pass." In your documentation, if you exclude anything from that area of care that Excelsior designates as a critical element, it's a point of failure. If at any time you place the patient in emotional or physical jeopardy, you fail. Failure while in the room is usually signaled by the CE stating, "I need you to step into the hallway with me." (When I heard those words it didn't occur to me that I had failed that PCS, I thought, "Hmmm, I wonder what she wants!" Hahaha. DUH!)

Why do people fail?

It's usually the little things that get most people. For example, I didn't ID my patient properly in what should have been my last PCS-oops! I asked the patient's name, but failed to compare her armband with the Kardex and ID her by two identifiers, because I lost focus when the patient started in to a litany of complaints.

Other reasons people fail: leaving required parts of the documentation form blank, forgetting to aspirate during the IVP station, breaking sterile technique on the wound, throwing syringes in the trash in the labs, drawing up the wrong amount of meds, forgetting to roll insulin, running out of time on the labs, and on and on. The little things.

The CPNE is all basic stuff, but in a nerve-wracking framework. Students have a total of three (rather expensive) chances to be successful at the CPNE, after which they are dismissed from the program. It's a lot of pressure to have hanging over one's head, especially if you tell everyone you know that you're going (like I did), and you have an RN job waiting for you based on the outcome (like I did).

Is it fair?

Are there things about the CPNE that are not fair? Surely there are; the nature of the exam is very subjective. The CA is human. The CEs are human. The patients are human. We are SUBLIMELY human. The CPNE is not human, it is a framework in which we have to be so very human while functioning exceptionally/perfectly while under extreme stress. Even more than five years later, I don't quite know how I feel about the CPNE-it hurts my heart to see others fail, but I know that the CPNE is a necessary part of this program. I came out of my CPNE not liking it, but surely respecting it.

I know how awful it can feel to nearly fail the CPNE-been there, done that, burned the t-shirt. After failing what should have been my final PCS in the first 20 minutes on Sunday, I paced a hallway for two hours, waiting for a CE to be available for my final, do-or-die PCS, and I paced so much I wore holes in my heels and bled through my socks and onto my white shoes (stupid Keds). I was terrified they wouldn't let me attempt the final PCS because I was bleeding, I completely skipped over "blistered" and went straight for "open wound."

With all that being said, I felt my exam was very fair. Did I fail an adult PCS? You betcha! All by myself, I did, with the bonehead omission of properly identifying my patient in the first few minutes I was in the room. I could blame the CE because she was obviously new and nervous and weirdly timid, or I could blame the patient because she was cranky and gruff and obviously wanting to stir the pot and cause trouble for the poor little nursing student the minute I walked in. I could say that the planning process started poorly, with the primary nurse not being able to give me vital sign parameters for which I'd hold the patient's dose of Digoxin (yes, really), once we were able to even LOCATE said primary nurse, all of which ate into my planning time greatly. All these things that I didn't even bother to put into my journal; they rattled me, surely, but the failure was MINE, and I owned it, I claimed it, I knew it.

All of us at Mansfield made it to the third day, with the exception of the student who failed all 4 labs on Friday night and just didn't show up Saturday morning; I'm not really counting her in this, because she gave up before she even really failed. The only other person who failed that weekend failed on Sunday, after this person made what they themselves called a "stupid error," and then failed a second PCS for physical jeopardy involving a tube feeding and lowering the head of the bed. This person was VERY angry and told me in the hallway (as I paced and bled) that if I failed my final attempt, I should retest elsewhere because Mansfield wasn't fair. I disagreed, told this person that I FAILED all by myself, said I planned to be successful that afternoon, and I turned and walked away because I couldn't be sucked into the negativity at that point (and I needed to do more pacing, more bleeding, ha ha). And in that moment, I realized I'd get this person's CE for my final PCS ... and she was the CE I feared the most, because she was utterly straight-face, robot-like, and thus intimidating (but strangely enough, exactly my height! LOL). But this CE showed me her human face for an instant during my PCS as she smiled and stroked the cheek of my demented 90-year-old patient, and I knew in that moment that I could pass this final PCS. And so I did.

Let me explain ... no, there is too much. Let me sum up

Hope that helps give you some idea of what the CPNE entails. For those of you preparing, good luck! You can do this. It's not impossible. For those of you considering Excelsior, just be aware that this can be a difficult end to what is often a long journey. I recently saw some Facebook comments to the effect of "If I'd really known what the CPNE was like, I would have gone to a traditional program." I think they were only half kidding!