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After the pinning ceremonies are done and the diplomas are handed out many nursing students feel that their lives as Registered Nurses (RN’s) have begun. Then the reality of needing to pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN) sets in. Statistics show that between 10%-18% of students do not pass the NCLEX-RN on their first attempt (Registered Nurses' Experiences of Passing the NCLEX-RN After More Than One Attempt | Journal of Nursing Education (healio.com). A failed attempt at the NCLEX-RN is a devastating blow to many. Rhoda Sommer, MSN-ED, owner of One on One NCLEX Tutor and coauthor of the book NCLEX-RN for Dummies, is all too familiar with that devastation. The Shame Associated with Being Unsuccessful Sommer, an RN who tutors students after a failed attempt (or two) at the NCLEX-RN, says counseling students who are heartbroken is a big part of her job. “A person’s self-worth drops like crazy, and in the first session with a student, all they do is cry,” Sommer says. According to Sommer anxiety is common, and a person needs to grieve before they are ready to begin to study to retake the NCLEX-RN. According to Dr. Tammy Kasprovich in a 2017 study of students who failed their first attempt at the NCLEX-RN, a person’s feelings of depression lasted anywhere from a few days to a few months. That study also found that it is important for students to change their negative self-talk if they are to ultimately succeed at the NCLEX-RN. Rhoda Sommer says she finds celebration of small successes is an important part of her work with students. Sommer says she celebrates each benchmark a person passes. According to Kasprovich, some students find the support of close friends and family important when preparing to take the all-important exam a second time, but Sommer says she has seen the pressure family and friends can add also. “It’s hard when a spouse or parent is saying ‘You can’t do this’ when {a student} knows they need to do this.” Sommer says. Pressure All Around Students who fail their first attempt at the NCLEX-RN often report feeling both internal and external pressure before the initial attempt. One source of stress comes when a student already has a job as a graduate RN in a hospital. These graduate RNs have been working as Registered Nurses in the hospital and making Registered Nurse salaries when they are suddenly demoted to nurse tech after their unsuccessful NCLEX attempt. Some students, having secured positions as graduate nurses, have bought cars or rented expensive apartments before passing the NCLEX. To add insult to injury, neither hospitals nor nursing schools provide much support for graduate nurses who do not pass the NCLEX on the first attempt, and some would-be RN’s have reported being dismissed by once-friendly peers when they do not pass the test. In fact, hospitals often give a student a deadline by which they need to reattempt the NCLEX-RN, adding to the examinee’s stress level. If Sommer had one piece of advice to offer students preparing to take the NCLEX-RN, it is this: Pass the NCLEX-RN first, then get the job, the car and the apartment. The NCLEX-RN is stressful enough without the added pressure, she says. Failing to Plan/Planning to Fail Many people who fail the NCLEX on their first attempt are stunned and many have failed to adequately prepare for the exam the first time, Sommer says. Some think they can wing it and pass the NCLEX-RN. Many students who come to her got A’s in nursing school and were a leader of study groups, says Sommer. She says many students just don’t study for the exam. Students sometimes believe they can rely on “tricks”-rumored strategies about what answer to choose if a test taker does not know the answer to a question. For example, it is a rumor that if there is a question about diet and you don’t know the answer, select the answer that involves chicken. Such tactics are rarely good test-taking strategies. Sommer also advises that planning a vacation just before the exam is not a good idea. Similarly, it’s best to reschedule the test if you are sick or there has been a major unforeseen life stress (such as a death in the family) just before the exam. Sommer says it is best to avoid anything that disconnects you from NCLEX material just before the test. Winning Strategies for Success Kasprovich found that strategies that help people pass the NCLEX-RN include looking for keywords, not reading too much into a question, and eliminating obviously wrong answers. In Kasprovich’s study, students who took and passed the NCLEX-RN a second time practiced NCLEX style questions to build their confidence. Rhoda Sommer employs the same strategy at her private business, One on One NCLEX Tutor. Sommer says students in her program are encouraged to take as many questions as they can per day, and that can be as many as 300 NCLEX-RN style questions. Conclusion After nursing school graduation it can be devastating for individuals who do not pass the NCLEX RN the first time. It can seem that everyone around them is passing the test and moving on. There is still room for success, and the help is there for those who look for it. Rhoda Sommer helps people find success on the NCLEX-RN the second time around. She says she has found her dream job. References Kasprovich, T. P., & VandeVusse, L. P. (2018, April). Registered Nurses' experiences of passing the NCLEX-RN after more than one attempt. Journal of Nursing Education, 57(10), 590-597. doi:10.3928/014834-20180921-04 Sommer, R. (2021, September 24). MSN, ED, Nursing educator. (M. R. Ellen Cole, Interviewer)

When it comes to healthcare, veterans of the armed services sometimes have unique behavior issues which may require specialized care. Abraham Lincoln established the Veterans Health Administration (VHA) in 1865 “….to care for him who shall have borne the battle and for his widow and his orphan.” Not all military service members qualify for care at a VHA facility, however. On average, 600 veterans retire or resign from military service per day. Factors that determine a veteran’s qualification for VA care include discharge status (honorable, medical, general), service time and type of military experience. Behavioral Issues of Military Veterans without War Stories - ProQuest Forty percent of all Iraq and Afghanistan Veterans, plus an additional 10 million military service members who were not deployed seek care at civilian health care facilities. Behavioral Issues of Military Veterans without War Stories - ProQuest It is not always obvious if a patient has had military experience, so it is important to ask patients if they have ever been a member of the military. It is also important to know what branch of the service they were in and in which era (WWII, Vietnam, Iraq/Afghanistan) they served. Behavioral issues can and often do go hand in hand with physical complaints. In addition, behavioral diagnoses may accompany substance abuse or suicidal ideation. Veterans may have special behavioral issues which all nurses should be sensitive to and include in a thorough assessment. Post-traumatic Stress Disorder Post-traumatic stress disorder (PTSD) is triggered when a person experiences a terrifying event or series of events over time. After the event has ended patients with PTSD experience hypervigilance, anxiety or anger. Soldiers have experienced PTSD for generations and the disorder has gone by different names. PTSD was formally recognized in the 1980s. When approaching a Veteran who is anxious consider their trauma history. Ask the Veteran if they have been constantly on guard or are easily startled. It is common for vets with PTSD to feel guilt or blame themselves for past events. PTSD is linked to suicide and alcohol dependence. Suicide According to the National Veteran Suicide Prevention Annual Report, members of the armed services are 1.5 times greater risk for suicide than the civilian population. That makes assessing for suicide particularly important in the Veteran population. Suicide prevention strategies that work include universal screening, safety planning and cognitive behavior therapy. The VA has programs in place to help all service members, even those that don’t qualify for other VA medical care. Military Sexual Trauma As with suicide, the VA has programs in place for Veterans with military sexual trauma (MST) even if the Veteran doesn’t qualify for other services. MST is defined as any unwanted sexual conduct, including comments, unwanted attention and inappropriate verbal or physical conduct, up to and including assault. Between 13.9 and 31.2% of military service members have experienced MST. Assessment questions for MST include: Did you have unwanted or threatening sexual advances? Have you ever received frequent comments about sex? MST does not have to be documented in the Veteran’s service record for them to receive care at VHA. Depression Depression is another common ailment among military service members. Patients may have symptoms of depression without a diagnosis of clinical depression. Severe depression may lead to suicidal ideation and substance abuse. Patients with depression may be lethargic or withdrawn. Others may be angry or agitated. Many people may not show signs of depression. Depression is treatable, even in severe cases. Physical Health Concerns Common for Veterans Military service members have certain physical ailments at a higher rate than the general public. Those complaints include: Tinnitus - Veterans tend to have hearing issues such as tinnitus, or ringing in the ear. This is due to work environments which involve exposure to loud noise, including gunfire and aircraft and generators. Tinnitus may affect a former service member’s concentration and work performance and may lead to anxiety and depression. Musculoskeletal Injuries - Service members often carry heavy loads over difficult terrain, perform repetitive tasks, or wear protective body armor. These are just some of the activities that can lead to musculoskeletal injuries including rotator cuff damage, cervical and lumbar strain and knee damage. Conclusion Members of the military perform a service to the country, and that service sometimes leaves them with both physical and behavioral health problems. It is important to identify Veterans who may have these behavioral and physical issues as a result of their service. The VHA has special programs to help them recover from trauma even if they do not qualify for other outpatient services. Prompt identification and treatment of Veterans ‘physical and behavioral ailments can save lives. Views expressed here are solely those of the author. Ms. Cole does not write for VHA References Conard, P. P., Keller, M. P., & Armstrong, M. L. (2021, March/April). Behavioral issues of military Veterans without war stories. Medsurg Nursing, 30(2), 138-142. Contractor, A. A., Forkus, S. R., Monteith, L. L., Roselini, A. J., & Weiss, N. H. (2020, October). Military sexual trauma and alcohol misuse among military veterans: The role of negative and positive emotion dysregulation. Psychological Trauma: Theory, Research, Practice and Policy, 716-724. Elsevier -. (2021, May). Depression. Post Traumatic Stress Disorder, Suicide. Retrieved from Elsevier Clinical Skills: elsevierperformancemanager.com United Health Foundation. (2021). Public Health Impact: Suicide. Retrieved from America"s Health Rankings: https://www.americashealthrankings.org/explore/annual/measure/Suicide/state/ALL US Department of Veterans Affairs. (2021, April). celebrate VA motto. Retrieved from VA.gov: https://www.VA.gov/opa/publications/celebrate/vamotto.pdf Military sexual trauma and alcohol misuse among military veterans: The roles of negative and positive emotion dysregulation