Why are Hospitals so darn mean when someone fails the NCLEX?

[Roland]

My wife works at an Indianapolis facility and one of her friends (not the same one referenced in a seperate post) just failed the NCLEX. Here's how they handled the situation:

1. She was stopped midshift and called into the office after the hospital checked the Internet state site and learned that she failed.

2. Her patients were immediately taken away. She was bumped back down to a student nurse from $20.00 to $10.00 per hour base (which actually means she will go from about $28.00 to $11.00 per hour since she works weekend/nights).

3. The worst part is that they will put her name in the hospital newsletter as failing the NCLEX. When she asked why she was told that they do it to "help" the person since people will know they failed and can thus offer emotional support!

Look, I know that passing the NCLEX is a big deal. However, couldn't they just cut the pay by say $3,00 per hour and mandate some remedial classes (they don't even offer the remedial classes until you've failed at least twice). This girl was a good student, who took the Kaplan course and is considered excellent clinically.

[Lawnurse]

I have to agree, although it isnt really right, but i agree with your possible reasoning. However, to the OP,there is no way they can keep her in the position if she has failed NCLEX. The basis of hiring is with the assumption you will pass and if you dont "officially" you dont have verification of competancy to be kept in the position.

Sorry but rules are rules for a reason.

No. Even if the basis of hiring is the idea that you will pass, GNs are not allowed to do RN-duties on "the assumption that you will pass" - that is against the law.

If the hospital was asking a GN to do - or letting a GN - do anything more than a GN can legally do without a nursing license, on "the assumption" that he/she is about to pass, that is called "the unauthorized practice of nursing" and is illegal.

Is, for example, "a really smart new grad who is definatly going to pass when she takes it next week" an RN? No.

If your (3rd person you) hospital is letting new grads "practice nursing," on the assumption that he/she is about to pass, duck and CYA.

All the failure of NCLEX signifies is that person is not licensed to be an RN. It doesn't make you not a GN anymore.

[zambezi, BSN, RN]

The hospital offers the GN a position on the merit system that they will pass the Boards. Unfortunately, if they do not, they are removed from the position. This actually has nothing to do with the hospital, but the state that issues the license. The permit to work as a Graduate Nurse is null and void if the student doesn't pass.

This is one of the reasons that I suggest that the student take his or her boards before beginning their training. Remember that the hospital doesn't just put the nurse on the floor running, but invests in an orientation for them with a preceptor. There are also costs involved to the facilitity. There are actually quite a few hospitals that will no longer hire GNs because of this reason.

This is basically what my hosptial has gone to...There is a two week general orientation to the hospital (roles, responsibilites, pumps, policies, more school type stuff) and in order to start working with you preceptor on the floor you must first take and pass the NCLEX (though you can do this orientation class without taking the NCLEX). Apparently there were originally people not taking the test promptly and continuing to work with their preceptor for this "GN" pay (even as a GN we had to work with preceptors until off orientation) and you can imagine that this was not cost effective.

I don't agree with the hospital publishing her name for failing. I can see potentially posting a note or disucssing her new roles at the staff meeting for the floor though just so her coworkers can understand what she is and is not allowed to do. It sounds like it was not handled in the best way. It kind of reminds me of the quarterly note we get from out state board publishing the name of those that have had their licesenses suspended or revoked for various reasons...I am unsure of what her status should be as she is still an unlicensed graudate nurse. She is, of course, still a graduate nurse but now has to wait and extra couple of months to get a license....She should not be functioning as a nurse without a license even though she has graduated. I hope that it works out for her and that she passes the test on the next try....

[Lawnurse]

I can see potentially posting a note or disucssing her new roles at the staff meeting for the floor though just so her coworkers can understand what she is and is not allowed to do. .

There should be no change in what she is and is not allowed to do.

She was a GN yesterday - she is a GN today. :deadhorse

[INtoFL_RN]

Like the other posters, I don't think what happened to her was out of the ordinary. But I do think that it could have been handled better. They didn't need to pull her off the floor in the middle of the shift, and they don't need to post her name in the hospital newsletter unless she gives them permission to do so.

I worked as a student nurse in Indianapolis, then stayed on the same unit after I graduated. Our manager didn't consider anything about licensure official until we received written notice of passing/failing from the Board. There was someone in our orientation class that failed NCLEX - they did dock her pay, but she still worked under the supervision of her preceptor. The terms of our pay were disclosed to us when we were hired. It said that if we failed to pass boards, this, this, and this would happen. Maybe your friend needs to take a closer look at her job description and HR policies.

[MishlB]

Wow, ROLAND, I have to agree that you need to chill. Many hospitals keep GN's on as CNA's, hoping to keep them as a nurse once the boards are passed. They could easily let them go as well, not giving them ANY opportunities to learn on the job as well as continue to earn money. Critical thinking is what we do...and the NCLEX is not an easy test. Are you proposing we graduate and start working without a licensing exam? Medicine is not like the law in the way that there are many variables in different situations. (only an example, I am not familiar with passing the bar exam)

[BittyBabyGrower, MSN, RN]

When I started nursing 19 years ago, we were hired as GN's did our orientation and then took boards (boards were only offered 2x a year at the state fairgrounds). We signed GN after our names, but we did everything an RN did, including meds. That changed in the past 5-10 years and most places will not hire GN's because of the liability to the hospital for letting an unlicensed person perform RN duties. Yup, we were on our own with 4 patients, and it was really short staffed to boot, so you were on your own. Times sure have changed, and it is so for the better. I started that job the day after I graduated from nursing school in November and practiced as a GN until June when I could take my boards.

[JVanRN]

There should be no change in what she is and is not allowed to do.

She was a GN yesterday - she is a GN today. :deadhorse

Well, where I work, they won't even let us work as GN's without the state permit that states we are GN's. Our diploma/degree from the school showing completion of the program isn't enough. But at our hospital GN's pretty much can do what an RN does (but usually doesn't because lack of experience...I know that didn't make too much sense). They are not used as nurse aides. But I have seen hospitals that have so called "Nurse Apprentencies" that arent even out of school that work WITH nurses and give meds ect...and then I have seen hospitals that don't use GN's in that kind of roll at all/they work as aides until they become RN's but get paid more. So maybe it's more of a hospital policy thing.

I do think publishing her name was cruel too. The "emotional support" arguement is stupid. Maybe that was the intention but still stupid IMO.

About the pay...well if she's not performing the same duties...why should they pay her the same? Many places won't do this. Where I work they WILL pay you at the same GN rate for a few months after a person fails until they take the NCLEX again. If a person fails a second time the pay goes back to what it was before of the person is let go until they pass or they can work as a ward clerk of aide. I think this is very good.

Unfortunately I have seen so many people run out and make all these major purchases, they could not have afforded otherwise the second they get out of school without even having the letters RN behind their name yet, then when pay goes down to $7-8.00 an hour the person is left sweating.(don't know the point of this paragragh, and not suggesting the OP did this) Just be cautious to those who do.

That said, I wish your wife luck. Lots of people fail on the first try (most of them ARE smart). Most people fail because of nerves or something else not because they are dumb. Since she knows what to expect then maybe the 2nd time will be a little less stressful.

[Lawnurse]

They could easily let them go as well, not giving them ANY opportunities to learn on the job as well as continue to earn money.

This is not a strong statement - any employer can fire any employee at any time for (almost) any reason. Its called at-will employment which is what all nurses have.

I think we are being too hard on Roland. We all know one person who failed NCLEX the first time and ended up being a very decent nurse anyway. I venture to say that the NCLEX is not a highly valid test of a good or safe nurse. Remember how we had to learn to differentiate between the actual answer and the "ivory tower nursing" answer that was actually the correct answer on the NCLEX?

Or that we would get practice questions wrong because we answer the question in terms of the current technology that we actually use during clinical, forgetting for a moment that all NCLEX questions are at least 3 to 5 years old?

Or that you sometimes wanted to add "and then get sued for malpractice" to what you find out from the answer key was actually the correct answer?

And we have probably all chosen to forget the NCLEX questions that were just rediculous because they strayed so far from reality.

I remember a lot of questions going something like this:

Your patient is hemorrhaging from every pore of his body. The nurse should:

a) call for help

b) continue to breath, blink, circulate blood, and call for help

c) call for help before any subsequent blinking, breathing, or movement of blood

d) call for a pastoral consult as the patient is so obviously about to croak.

Not saying we don't need NCLEX, just trying to provide a reality check.

[mariedoreen]

Advertising it in the hospital newsletter is cruel. I'd rethink working at that facility.

Exactly what I was thinking! I'd stay there until I passed the NCLEX and the second they found out I'd turn in my resignation.. but then I can be a tad vindictive :chuckle

[Roland]

1. One, we are not talking about my wife, but one of her friends who failed the exam.

2. I'm not saying that the hospital has a legal obligation to do squat (although one might imagine that the tort of invasion of privacy might be committed by the act of publication. On the other hand this is public information and she may have given express or implied consent somewhere along the line). What I am saying is that they should do what many of you indicate that your facility does namely give the person a second chance before docking their pay.

3. I am suggesting that the NCLEX should be like 95% of other licensing examinations and test basic knowledge. After all the test is designed to ascertain minimal competency not mastery of the subject material.

4. I have expressed in different posts my belief that the NCLEX question design methodology is not sufficiently objective. I believe that every question should meet at least the following five criteria:

a. It should have been peer reviewed by at least two expert nurses who evaluate that there is only one best answer and that the author's answer is in fact that answer.

b. It should be able to specifically cite medical journals or recognized nursing literature which demonstrate that the correct answer is in fact correct.

c. The journals or texts that can be cited should be agreed upon ahead of time by an appropriate nursing body. In this way the potential student knows exactly what knowledge (and indeed perspective on that knowledge) they are responsible for knowing.

d. Every question would contain an explanation as to exactly why it was in fact the best answer.

e. Every test taker would have the opportunity to challenge any question with the payment of a minimal fee and a coherent explanation of why they felt a different answer was correct (note such an explanation would also have to contain appropriate citations from the approved body of literature).

A paid question review board (that was selected in a non bias manner from both practicing and academic nurses) would then review the objection and vote on the outcome. In this way the test would be constantly "peer reviewed" at multiple levels and would thus become progressively "better" .

Let me offer an example to illustrate how this might work. The following is a sample question taken from the Study Guide for Harrison's Principles of Internal Medicine (14th edition).

Question: You are a nurse on duty in the ER when a patient is brought in with a head injury. A fracture of which of the following bones is most closely associated with an epidural hematoma?

A. frontal

B. parietal

C. temporal

D. occipital

E. sphenoidal

Answer: The answer is C (Chap 374, White, N Engl J Med 327:1507-1511, 1992). Epidural bleeding may cause rapidly deteriorating mental status after an initial lucid interval following head trauma. Such hematomas occur in 1 to 3 percent of all head injuries. The typical profile of a patient with an acute epidural hematoma is that of an alcoholic who sustains severe trauma and fractures the squamous portion of the temporal bone, tearing the origin of dural vesssels arising from the middle meningeal artery. Therefore, the most common location of an epidural hematoma is overlying the lateral temporal convexity. These hematomas expand rapidly because of the force of arterial bleeding, strip the dura from the atttached inner table of the skull, and produce a characteristic bulge-type clot on CT. This dramatically evolving picture requires neurosurgical intervention, usually in the form of clot evacuation.

Note: A student facing this question may have experience in working at an ER located in a rough section of Philadelphia where boxing and street fights are common. Perhaps, given this unique environment they are used to seeing hematomas induced by injury to the frontal rather than the temporal bone. However, they will have been informed ahead of time (under my system) that the appropriate journal to reference on this topic is the New England Journal of Medicine (or in the case of my hypothetical NCLEX perhaps it would be the American Journal of Nursing among others). Furthermore, NCLEX review books, and undergraduate nursing courses would be taught from the perspetive of the approved body of nursing literature. Thus, everyone would be taught (at least until the literature is updated as it would every two to five years) that the most common presentation of a an acute epidural hematoma was an alcoholic who sustained damage to the temporal bone.

[zambezi, BSN, RN]

There should be no change in what she is and is not allowed to do.

She was a GN yesterday - she is a GN today. :deadhorse

I agree with you...however, if you reread the OPs original post you will see that she was pulled from the floor in the middle of her shift and her patient's were reassigned and she was "demoted" back to student nurse with a paycut. If she was still considered to be a GN by the hosptial's standards, then why was her assignment changed...I think that the hospital needs to clarify what the role of the GN is and if you don't pass how that role is expected to change (and they may have for all we know). If the role is different- which, in this case, it sounds like it may have been, then the staff on the floor needs to be notified of the change (though I am not sure how different the roles of the GN and student can be being that neither is licensed and both must have RN supervision).

Futhermore, I was unaware that you could be paid to work as a student nurse- maybe she was changed to CNA status? Just my thoughts...

As I originally stated, it is kind of a bum deal, but now she knows she needs to buckle down, pass the NCLEX (no matter how arbitrary it may be we still have to take it and pass), and then she can continue to work. Not passing the test seems like a fairly common problem, you would think that the hospital would have clearly defined guidelines in place that disucss options until the test can be retaken (and hopfully, this hospital does and we just haven't heard about it).

[Roland]

Exactly what I was thinking! I'd stay there until I passed the NCLEX and the second they found out I'd turn in my resignation.. but then I can be a tad vindictive :chuckle

By the way the facility in question is a magnet hospital and is considered one of the very best in the area.