ONLINE CASE STUDIES: HESI EXIT

EXAM SCORES AND

NCLEX-RN OUTCOMES
ANNE YOUNG, EDD, RN⁎, GLORIA ROSE, PHD, RN, FNP-BC†,
AND PAMELA WILLSON, PHD, RN, FNP-BC, CNE‡

Using data obtained for the 7th HESI Exit Exam (E 2) validity study, the value of Elsevier's online
case studies in assisting students to prepare for the E 2 and the National Council Licensure
Examination for Registered Nurses (NCLEX-RN) was investigated. Of the 137 randomly
selected schools of nursing, 72 (52.55%) participated in the study. The student sample consisted
of 4,383 students from associate degree, baccalaureate, and diploma schools of nursing. Findings
indicated that the mean E 2 score and the NCLEX-RN pass rate were significantly higher for
students attending schools that used the case studies than they were for students attending
schools that did not use the case studies. Descriptive data indicated that the case studies were
most often used for remediation and examination preparation. (Index words: Case study; HESI
Exit Exam; NCLEX-RN outcomes) J Prof Nurs 29:S17–S21, 2013. © 2013 Elsevier Inc. All rights
reserved.

S EVEN PREVIOUSLY PUBLISHED studies indicate

that Elsevier's HESI Exit Exam (E 2) is a highly
accurate predictor of success on the National Council
Licensure Examination for Registered Nurses (NCLEX-
RN) (Adamson & Britt, 2009; Lauchner, Newman, &
Britt, 1999; Lewis, 2005; Newman, Britt, & Lauchner,
2000; Nibert & Young, 2001; Nibert, Young, &
Adamson, 2002; Young & Willson, 2012). Consequently,
many schools of nursing use the E 2 as a predictor of
students' preparedness for the licensure examination and
as a guide for students' remediation needs. Numerous
subject matter scores reported by the E 2 provide students
with the information they need to focus remediation
∗Professor, Texas Woman's University, College of Nursing, Houston,
TX.
†Clinical Assistant Professor, Prairie View A&M University, College of
Nursing, Houston, TX.
‡Associate Director of Education, Michael E. DeBakey VA Medical
Center, Houston, TX.
Disclosure statement: Dr. Young and Dr. Rose have participated in
research activities and received presentation honoraria from HESI
Review & Testing within the past 3 years. Dr. Young serves as
Chairperson of the Research Advisory Board for HESI Review & Testing.
Dr. Willson was employed by HESI Review & Testing at the time this
research was conducted.
Address correspondence to Dr. Young: Texas Woman's University,
College of Nursing, 6700 Fannin, Houston, TX 77030. E-mail: eyoung@
mail.twu.edu
8755-7223/12/$ - see front matter
Journal of Professional Nursing, Vol 29, No. 2S (March/April), 2013: pp S17–S21
© 2013 Elsevier Inc. All rights reserved.
efforts that address their particular learning needs.
However, methods used to prepare students for the
licensure examination and to remediate academic
weaknesses identified by the E 2 so that candidates
can achieve first-time success on the NCLEX-RN have
not been adequately researched. A plethora of NCLEX-
RN review books designed to assist students in
reviewing content presented throughout the nursing
curriculum are available for purchase. Yet, knowledge
of content alone is not sufficient to achieve acceptable
E 2 scores, pass the NCLEX-RN, and perform compe-
tently in the clinical area. Students and new graduates
must also be able to apply nursing content and
concepts to specific clinical situations and use critical
thinking skills to solve clinical problems.
Review of the Literature
Case studies have long been used as a teaching method in
business, law, and medicine because they provide an
effective means of applying content and assisting
students to develop problem-solving skills (Delpier,
2006). The use of case studies for teaching is generally
considered superior to lectures in promoting learners'
critical thinking skills, and students report a preference
for interactive teaching strategies over didactic methods
(Kim et al., 2006). Interestingly, despite students' pre-
ference for interactive teaching strategies and faculties'
belief that case studies are superior to didactic teaching
S17
http://dx.doi.org/10.1016/j.profnurs.2012.06.010
S18
methods, little or no difference has been found in terms
of students' learning outcomes when comparing the use
of case studies and didactic teaching strategies (Beers,
2005; Costa, van Rensburg, & Rushton, 2007; Lauver,
West, Campbell, Herrold, & Wood, 2009). However,
studies that compared teaching methods could have
been affected by the methods used to evaluate learning
outcomes, which were usually traditional tests that
measured knowledge of content, rather than exams
designed to measure critical thinking. The E 2 and the
NCLEX-RN, both of which are designed to measure
critical thinking within the discipline of nursing, might
be a better measure of the effectiveness of case studies
in terms of students' learning outcomes. The use of case
studies as a teaching strategy in nursing has been
reported to promote critical thinking, develop students'
clinical reasoning skills, and enhance students' prob-
lem-solving abilities (Dowd & Davidhizar, 1999).
With the advent of instructional technology, innova-
tive teaching strategies have been developed to assist
students in achieving curricular and licensure success
using self-paced learning opportunities. The online case
studies provided by Elsevier are self-paced learning
tools designed to assist students with the application of
nursing knowledge and concepts in clinical situations,
and as such, they are believed by many faculties to be
an effective teaching strategy in helping students
prepare for the E 2 and the NCLEX-RN. Schools of
nursing may purchase a license to use the Elsevier case
studies, which are marketed as patient situations
accompanied by critical thinking questions that help
students learn to manage complex patient conditions
and make sound clinical judgments. However, limited
research has been conducted to study the effectiveness
of these case studies as a teaching tool and/or a
remediation resource.
Mihal (2006) is the only study completed to date that
has investigated the effectiveness of Elsevier's online case
studies. Using data obtained from Elsevier's database,
Mihal divided schools into two groups: those that were
licensed to use the case studies and those that were not
licensed to use the case studies. Then, the mean E 2 scores
for these two groups were compared. The mean E 2 score
for the 1,544 students who attended the 34 schools of
nursing that were licensed to use the case studies was
896.71, and the mean E 2 score for the 21,241 students
who attended the 344 schools of nursing that were not
licensed to use the case studies was 859.88. A t test for
two independent samples was used to compare the mean
E 2 score of students who attended schools that were
licensed to use the case studies with the mean E 2 score of
students who attended schools that were not licensed to
use the case studies. Findings indicated that the mean E 2
score for those who attended schools that were licensed
to use the case studies was significantly higher (t = 9.979,
P ≤ .000) than the mean E 2 score for students who
attended schools that were not licensed to use case
studies, thereby suggesting that Elsevier's online case
studies positively affected students' E 2 scores.
YOUNG ET AL
This study was designed to verify Mihal's findings
regarding the E 2 scores of students with and without
access to case studies. However, since the Mihal study
was completed, case studies' licenses have become a
component of several testing packages, and current
access to them does not necessarily mean that they are
being implemented as a teaching strategy. This study
determined users and nonusers of case studies based on
deans' and directors' reported use of the case studies,
rather than merely having a license to use the case
studies. For the purpose of this study, two terms were
defined: (a) case studies—Elsevier's online case studies
that were licensed for use to schools of nursing; and (b)
users of case studies—students who attended schools of
nursing where deans and directors identified their school
as a user of the case studies. Specifically, the purpose of
this study was to (a) determine if E 2 scores of students
who used the case studies differed from E 2 scores of
students who did not use the case studies, (b) determine
if NCLEX-RN outcomes of candidates who used the case
studies differed from NCLEX-RN outcomes of candidates
who did not use the case studies, and (c) describe the
methods used to implement the case studies.
Methodology
A nonexperimental, descriptive design was used to
compare E 2 scores of students who used Elsevier's online
case studies with E 2 scores of students who did not use
the case studies. As part of the seventh E 2 validity study
(S7), data were obtained from deans and directors at 72
randomly selected schools of nursing that administered
the E 2 between September 1, 2006, and August 31, 2007
(Young & Willson, 2012). These participating deans and
directors were asked to complete the S7 Participant
School Survey, an electronic instrument that requested
information regarding NCLEX-RN outcomes and use of
the case studies. Additionally, data obtained from the
three questions on the S7 Participant School Survey
regarding case study implementation methods were used
for descriptive purposes.
Instrumentation
Two instruments were used to obtain data for this study:
the E 2 and the S7 Participant School Survey. The E 2
consists of 160 test items, 10 of which are pilot items that
are not scored. It is a comprehensive exam that is
administered to students near the completion of the
nursing curriculum to measure their preparedness for the
NCLEX-RN. The test items are written using a critical
thinking model described by Morrison, Nibert, and Flick
(2006) and require clinical nursing judgment to deter-
mine the correct answer. Morrison, Adamson, Nibert,
and Hsia (2004) described the reliability and validity of
the E 2 . A reliability estimate or Kuder–Richardson
Formula 20 (KR20) is calculated for every E 2 prior to
its administration and is based on item analysis data
obtained from all previous uses of the test items
contained in the exam. The mean estimated KR20 for
the E 2s administered during the study period was 0.926
ONLINE CASE STUDIES S19

Table 1. Description of Schools and Students by Program Type
and HESI Case Study Use
Number of Number of
schools students
Program type
ADN 45 2,557
BSN 22 1,617
Diploma 5 209
Total 72 4,383
HESI case study use
Used the case studies 24 1,597
Did not use the case studies 48 2,786
Total 72 4,383
(Elsevier's HESI database, August 2011). Criterion-
related validity of the E 2 has been established by the
seven validity studies that have been conducted over the
past 12 years, indicating that the E 2 is between 96.36%
and 99.16% accurate in predicting NCLEX-RN success
(Adamson & Britt, 2009; Lauchner et al., 1999; Lewis,
2005; Newman et al., 2000; Nibert & Young, 2001;
Nibert et al., 2002; Young & Willson, 2012).
The S7 Participant School Survey consisted of multi-
ple-choice items with open comment fields. Data
obtained from this instrument were used to determine
students' outcomes on their first attempt at taking the
NCLEX-RN and to glean descriptive data regarding
strategies used to implement the case studies. All
identifying information was removed prior to providing
data to the researchers regarding NCLEX-RN pass rates
and case study implementation methods.
Findings
Nursing schools were randomly selected to participate in
S7, and of the 137 schools selected for participation, 72
(52.55%) responded to the Participant School Survey. Of
the 72 responding nursing schools, 45 (62.50%) were
associate degree (ADN) programs, 22 (30.56%) were
baccalaureate (BSN) programs, and 5 (6.94%) were
diploma programs. The total student sample consisted
of 4,383: 2,557 (58.34%) ADN students; 1,617 (36.89%)
BSN students; and 209 (4.77%) diploma students. Of the
72 participating schools, 24 (33.33%) schools reported
that they used the Elsevier online case studies within
their school of nursing, and 48 (66.67%) reported that
they did not use the case studies. Of the total 4,383
Table 3. NCLEX-RN Outcomes of Students Who Attended
Schools That Used HESI Case Studies and Students Who
Attended Schools That Did Not Use HESI Case Studies
Number Number
(%) passed (%) failed
HESI case studies Number NCLEX-RN NCLEX-RN
Students attending 1,437 1,332 (92.69) 105 (7.31)
schools that used
the case studies
Students attending 2,484 2,223 (89.49) 261 (10.51)
schools that did
not use the
case studies
Total 3,921 ⁎
Note. The NCLEX-RN pass rate was significantly higher for students who
attended schools that used the HESI case studies than for students who
attended schools that did not use the HESI case studies, χ2(1, N = 3,921)
= 10.64, P ≤ .001.
⁎ NCLEX-RN outcomes were not available for 462 of the total sample
of 4,383.
participating students, 1,597 (36.44%) attended schools
that used the case studies, and 2,786 (63.56%) attended
schools that did not use the case studies (see Table 1).
The mean E 2 score of the 1,597 students who used the
case studies was 868.79, and the mean E 2 score of the
2,786 students who did not use the case studies was
849.62. A t test analysis indicated that the students who
used the case studies had significantly higher E 2 scores
than the students who did not use the case studies,
t(3,229) = 4.58, P ≤ .000, (see Table 2).
Of the 4,383 participating students, NCLEX-RN out-
comes were unavailable for 462 students because they did
not graduate, their NCLEX-RN outcomes were unavail-
able to their deans or directors, or the deans or directors
declined to provide the data. Therefore, the total student
sample used for analysis regarding NCLEX-RN outcomes
consisted of 3,921 students: 1,437 (36.65%) who used the
case studies and 2,484 (63.35%) who did not use the case
studies. Of the 1,437 students who used the case studies,
1,332 (92.69%) passed the NCLEX-RN on their first
attempt, and 105 (7.31%) failed. Of the 2,484 students
who did not use the case studies, 2,223 (89.49%) passed
the NCLEX-RN on their first attempt, and 261 (10.51%)
failed. Because NCLEX-RN outcomes are reported as
pass/fail, which are nominal-level data, a chi-square was
used to analyze the data. Findings indicated that
significantly more students who used the case studies

Table 2. Comparison of Mean E 2 Scores for Students Who Attended Schools That Used HESI Case Studies and Students Who
Attended Schools That Did Not Use HESI Case Studies
Confidence
2 interval 95%
Mean E
HESI case study use n score SD t P Lower Upper
Students attending schools that used the case studies 1,597 868.79 135.07 4.58 ≤ .000 10.95 27.37
Students attending schools that did not use the case studies 2,786 849.62 130.39
Total students 4,383
Note. Mean E2 scores were significantly higher (P ≤ .000) for students who attended schools that used HESI case studies than for students who attended
schools that did not use HESI case studies.
S20
Table 4. HESI Case Study Implementation Methods Described
by Schools of Nursing That Used the HESI Case Studies
Number of Percent of
Method schools schools
Remediation 18 75.00
Exam preparation 15 62.50
Course grade 8 33.33
Clinical preparation 6 25.00
Postclinical conference 5 20.83
Total 24 ⁎
⁎ More than one method may have been implemented by individual
schools.
passed the NCLEX-RN on their first attempt than
students who did not use the case studies, χ 2(1, N =
3,921) = 10.64, P ≤ .001, (see Table 3).
Deans and directors of the 24 schools that reported
using the case studies answered three questions on the S7
Participant School Survey regarding methods used to
implement the case studies within their school of
nursing. Based on data obtained from responses to
these questions, the primary uses for the case studies
were remediation and exam preparation. Of the 24
schools that used the case studies, 18 (75.00%) deans or
directors described using the case studies for remedia-
tion, and 15 (62.50%) described using the case studies for
exam preparation. The case studies were used as part of
the course grade by 8 (33.33%) of the schools, for clinical
preparation by 6 (25.00%) of the schools, and for
postclinical conferences by 5 (20.83%) of the schools
(see Table 4).
Summary, Discussion, and
Recommendations
This study was based on data obtained for S7, which
investigated the predictive accuracy of the E 2 by
soliciting information from the deans or directors of the
participating schools regarding students' NCLEX-RN
outcomes. Data regarding schools' use of the Elsevier
online case studies were reported by the deans or
directors that responded to the S7 Participant School
Survey. Mean E 2 scores and NCLEX-RN pass rates of
students who used the case studies and those who did not
use the case studies were compared. Both E 2 scores and
NCLEX-RN pass rates were significantly higher for
students who used the case studies. It is likely that E 2
scores and students' first-time NCLEX-RN success rate
were higher for those who used the case studies because
the case studies focus on application of content and
require the use of critical thinking skills to answer the
questions provided with each case study. The online case
studies therefore provide students with valuable practice
in using their nursing knowledge and critical thinking
skills to solve clinical problems. However, the percentage
of students at each school who completed the case studies
and the percentage of case studies each student
completed could not be determined. In reviewing the
findings of this study, one must consider that the mean
YOUNG ET AL
scores could have been influenced by intervening vari-
ables. For example, it is possible that the faculty at
schools that used the case studies worked more closely
with students in helping them remediate than did the
faculty at schools that did not use the case studies, which
might explain why they purchased the case study license
in the first place—to help students remediate. Such
faculty assistance might explain why students who used
the case studies had higher E 2 scores and a higher
NCLEX-RN pass rate than students who did not use the
case studies. Additionally, the quality of the student
population at each school could have differed, thereby
influencing the findings of this study. Future studies
regarding the usefulness of case studies should investi-
gate the E 2 scores and NCLEX-RN outcomes of
individual students, and researchers should also consider
stratifying the sample by the number of the case studies
each student completed, rather than simply looking at
those who attended schools that reported using the case
studies. As it was in this study, all identifying student
information should be expunged prior to providing the
data to the researchers so that the participants' confiden-
tiality is protected.
This was a preliminary study that investigated methods
used to implement case studies and, as such, provided
descriptive data only. Future studies should obtain a
larger sample size of schools that use the case studies and
compare case study implementation methods in terms of
E 2 scores and NCLEX-RN outcomes, thereby scientifi-
cally investigating the value of various methods used to
implement case studies within schools of nursing.
Conclusions
Seven previously published studies indicate that the E 2 is
highly accurate in predicting NCLEX-RN success, and
the findings of this study provide nursing students and
nursing faculty with direction in terms of preparing for
the E 2 and ultimately for the NCLEX-RN. Deans and
directors reported that Elsevier's online case studies were
most often used for remediation and exam preparation. It
seems that the case studies were helpful with remedia-
tion and exam preparation because both the mean E 2
score and the NCLEX-RN pass rate were significantly
higher for students who used the case studies than for
students who did not use the case studies. It would
therefore seem judicious for deans and directors to
consider using the Elsevier online case studies to assist
students in preparing for the E 2 and ultimately for the
licensing exam.
References
Adamson, C., & Britt, R. (2009). Repeat testing with the HESI
Exit Exam—Sixth validity study. CIN: Computers, Informatics,
Nursing, 27, 393–397.
Beers, G. W. (2005). The effect of teaching method on
objective test scores: Problem-based learning versus lecture.
Journal of Nursing Education, 44, 305–309.
Costa, M. L., van Rensburg, L., & Rushton, N. (2007). Does
teaching style matter? A randomized trial of group discussion
ONLINE CASE STUDIES
versus lectures in orthopaedic undergraduate teaching. Medical
Education, 41, 214–217.
Delpier, T. (2006). Cases 101: Learning to teach with cases.
Nursing Education Perspectives, 27, 204–209.
Dowd, S. B., & Davidhizar, R. (1999). Using case studies to
teach clinical problem-solving. Nurse Educator, 24, 42–46.
Kim, S., Phillips, W. R., Pinsky, L., Brock, D., Phillips, K., &
Keary, J. (2006). A conceptual framework for developing
teaching cases: A review and synthesis of the literature across
disciplines. Medical Education, 40, 867–876.
Lauchner, K., Newman, M., & Britt, R. (1999). Predicting
licensure success with a computerized comprehensive nursing
exam: The HESI Exit Exam. Computers in Nursing, 17,
120–125.
Lauver, L. S., West, M. M., Campbell, T. B., Herrold, J., &
Wood, G. C. (2009). Toward evidence-based teaching: Evalu-
ating the effectiveness of two teaching strategies in an associate
degree nursing program. Teaching and Learning in Nursing, 4,
133–138.
Lewis, C. (2005). Predictive accuracy of the HESI Exit Exam
on NCLEX-RN pass rates and effects of progression policies on
nursing student Exit Exam scores. Dissertation Abstracts
International, 66, 154B (UMI No. 3195986).
S21
Mihal, C. (2006). The impact of HESI case studies on the HESI
Exit Examination scores for nursing students preparing for the
National Council Licensure Examination for Registered Nurses.
Unpublished doctoral dissertation, Seton Hall University, South
Orange, New Jersey.
Morrison, S., Adamson, C., Nibert, A., & Hsia, S. (2004).
HESI exams: An overview of reliability and validity. CIN:
Computers, Informatics, Nursing, 22, 220–226.
Morrison, S., Nibert, A., & Flick, J. (2006). Critical thinking
and test item writing (2nd ed.). Houston, TX: Health Education
Systems, Inc.
Newman, M., Britt, R., & Lauchner, K. (2000). Predictive
accuracy of the HESI Exit Exam: A follow-up study. Computers
in Nursing, 18, 132–136.
Nibert, A., & Young, A. (2001). A third study on predicting
NCLEX success with the HESI Exit Exam. Computers in
Nursing, 19, 172–178.
Nibert, A., Young, A., & Adamson, C. (2002). Predicting
NCLEX success with the HESI Exit Exam: Fourth annual validity
study. CIN: Computers, Informatics, Nursing, 20, 261–267.
Young, A., & Willson, P. (2012). Predicting NCLEX-RN
success: The seventh validity study of the HESI Exit
Exam. CIN: Computers, Informatics, Nursing, 30, 55–60.