Graduates of For-Profit Nursing Schools Do Not Perform as Well on Nurse Licensure Test, Study Shows

Medical team including nurses

For-profit ownership of nursing school programs is significantly associated with lower performance on a national nursing licensure exam than public and nonprofit programs, according to a study published in the Journal of Nursing Regulation. The team of researchers at the George Washington University (GW) who conducted the study say it brings to light issues at the core of the nursing profession’s educational system that merit serious consideration by regulators.

The study represents the most comprehensive evaluation to date of performance on the National Council Licensure Examination (NCLEX) for nurses by graduates of all three types of nursing programs. The study included nurses who had received their bachelor of science in nursing, associate degree in nursing, and practical nurse degrees.

“The premise of the nurse licensure exam is that there is a direct link between nursing education quality and the quality of nursing services delivered to the U.S. public,” says Patricia Pittman, PhD, the lead study author. She is a professor of health policy and management at GW’s Milken Institute School of Public Health and the co-director of the GW Health Workforce Institute. The findings have implications for the nursing workforce at a time when some parts of the country are facing nursing shortages.

As part of their study, Pittman and her colleagues tracked the number of U.S. nursing programs and graduates by ownership type from 2007 through 2016. The research team found a 14-fold increase in the number of graduates from for-profit nursing school programs during the study period. The study also documented a five-fold jump in the total number of for-profit nursing programs during the period.

The data that the team gathered on first-time nursing exam pass rates for graduates cover the five-year period from 2011 through 2015. By sorting that data by both degree and ownership status, the researchers noted wide variation in the performance trends within the for-profit sector. However, their analysis showed that the average pass rates among for-profit programs was lower and that it declined over the study period, while public and nonprofit programs’ pass rates stayed about the same.

The team’s descriptive analysis of five years of pooled data across the three degree types found that the pass rates of students taking the exam for the first time were 88 percent for public programs, 84 percent for nonprofits and 68 percent for for-profits. Graduates of associate degree in nursing programs at for-profit schools had the lowest scores.

After controlling for school, program, socioeconomic and other factors that could affect performance, for-profit ownership status was still a significant predictor of lower NCLEX pass rates. The regression models indicate that for-profit nursing programs had pass rates that were 7 percentage points lower than public programs. Nonprofit programs also had lower pass rates than public programs, but the magnitude of the difference was smaller at 2 percent, the authors said.

“Many states and accreditation agencies consider an NCLEX pass rate of at least 80 percent as a minimum quality threshold for nursing programs,” Pittman says. “Our study found that for-profit nursing programs were nearly twice as likely to have failed to meet that 80 percent threshold as compared to public programs.” Students who fail the NCLEX can take the exam again, but they cannot get an entry-level nursing job until they pass the $200 test, she explains.

This study used the NCLEX pass rates as a measure of a nursing school’s quality, an imperfect yardstick to be sure, Pittman said. However, she adds that it is one of the few ways to gauge a nursing school’s ability to prepare newly minted nurses for the demands of an entry-level job.

“In the context of the Trump administration’s interest in rolling back Obama-era education regulations, our findings take on new relevance,” Pittman and her colleagues write. “The topic of education regulation will likely be hotly debated in the coming years.” The issues at stake for nurses include the financial welfare of new nurse graduates, many of whom carry significant student debt as they struggle to pass their licensure examination and gain entrance to the marketplace. The findings also have implications for the size of the nurse pipeline as the country faces nursing shortages in some geographic areas.

The findings suggest that nursing leaders and policymakers at both the federal and state levels must take a hard look at the performance of all nursing programs, not just those in the for-profit sector. For example, Pittman said that not all states require accreditation at the nursing program level, and that accreditation could help ensure that all nursing schools meet a higher bar in performance standards.

In addition, states could also require nursing programs to publicly report their NCLEX pass rates, she said. Such disclosure could help prospective students size up the value of a nursing program regardless of its ownership status.

In addition to Pittman, the authors of “The Growth and Performance of Nursing Programs by Ownership Status,” are Emily Bass, BA, Xinxin Han, MS and Ellen Kurtzman, PhD, MPH, RN, FAAN.