Nursing education in Ghana is regulated by the Nursing and Midwifery Council (NMC) for the purpose of rationalizing the training and education of nurses and midwives and the maintenance and promotion of standards of professional conduct and efficiency. The council was set up under the statutory mandate of the National Redemption Council Decree (NRCD) 117 of the 1972 and L.I. 683 of 1971 [
Student nurses who successfully graduate from nursing programs must pass the licensure examination in order to be registered as nurses.
Currently, the licensure examination is held biannually, in February and August. The examination is in two parts, a practical and a theoretical session. The practical component requires that student nurses utilize the nursing process to identify patients’ problems, plan, and intervene. Using an Objective Structured Clinical Examination (OSCE) tool, the student is further observed when intervening in the problems identified. The theoretical component has six papers comprising medical and surgical nursing, mental health nursing, paediatric nursing, public health nursing, and obstetric nursing. Every student pursuing nursing must meet the standards of the NMC by passing each of the six examination papers with a minimum of 50% to be eligible for professional registration by the Nursing Council of Ghana. Success in the licensure examination is therefore the only legal prerequisite to practice as a nurse within Ghana. Failing in any paper means that the candidate must pay the full fees again to retake the examination when next offered.
In recent times, however, a large number of students who sit for the council’s licensure examinations (NMC-LE) fail on their first attempt [
In 2013, the Nursing and Midwifery Council of Ghana commissioned a team of experts from the universities of education (universities mandated to produce professional educators in Ghana, e.g., University of Education, Winneba) in Ghana to investigate the possible factors that account for the poor performance of the nursing and midwifery trainees in the council’s licensing examination. Major findings of the study involved school-related, tutor-related, and student-related factors [
Failure to understand these factors prevents the design of remediating interventions to help students who are at risk of failing the licensing examination. Recently, heads of some of the nursing institutions have come into a general consensus to register only students with high CGPAs in the licensure examinations. This decision was however based on their observation that students with good performance in the nursing training school tend to perform better in the licensure examinations. There is currently no empirical evidence on the relationship between nursing institution performance and licensure examination. A study by Stewart et al. [
This was a descriptive cross-sectional survey conducted from November 2014 to April 2015 in the Kumasi metropolis, Ghana. The study involved students of the Kumasi Nursing and Midwifery Training College and Seventh-Day Adventists (SDA) Nursing and Midwifery Training College. The Kumasi metropolis has a number of health facilities in both the public and private sectors. Notable among them is the Komfo Anokye Teaching Hospital (KATH), which is one of the two (2) national autonomous hospitals, four (4) quasihealth institutions, and five (5) healthcare centres owned by the Church of Christ and the Seventh-Day Adventist Church. In addition, there are over two hundred (200) known private health institutions and thirteen (13) industrial clinics in the metropolis. There are nine (9) Maternal and Child Health (MCH) points and one hundred and nineteen (119) outreach sites.
A total of about fifteen (15) institutions are involved in the training of nurses and midwives in the Ashanti region. The Medical Mission Sisters of the Kumasi Church founded Kumasi Nursing and Midwifery Training College in 1957. Currently, it offers two basic diploma programs, nursing and midwifery. It is affiliated to the Komfo Anokye Teaching Hospital in Ghana and its activities are supervised by the Ministry of Education. The institution is accredited by the National Accreditation Board and now awards direct diploma to students after completing a three-year training programme. The school has a total population of about 1200 students. Seven hundred (700) of these students are pursuing diploma in general nursing course while the rest are studying diploma in midwifery.
The SDA Nurses and Midwifery Training College was established in October 2005 by the Central Ghana Conference of the Seventh-Day Adventist Church with the support from Ministry of Health, Ghana, and Kwadaso S.D.A. Hospital. It is located at Kwadaso, a suburb of Kumasi municipality. The school currently has a total population of 720 students and has produced about 1200 nursing graduates since its inception.
The survey involved all past 178 students from the two institutions who sat for the licensure examinations. This involved 83 students from Kumasi Nursing and Midwifery Training College and 95 students from the SDA Nurses and Midwifery Training College. Two students, one from each facility, could not complete the questionnaire so were excluded from the study.
Data for this study were collected mainly through interviewing. Participants were interviewed at their various locations (home or health facility) after prior appointments. Participants signed a consent form after the purpose of the study was explained to them and they agreed to participate in the study. Data collection was done with structured questionnaire, which was pretested to check for clarity, consistency, and acceptability of the questions to respondents. All questionnaires and interview results from the field were checked for completeness and internal errors during data collection.
Data were analyzed using SPSS version 22. The main outcomes of the study were students’ performance in the licensure examinations and CGDP at the end of the three-year training. Outcome of Licensure examination was coded as “0 = fail” and “1 = pass.” CGPA was treated as a continuous variable and also categorized into class designations (first class, 3.6–4.0; second class upper, 3.0–3.59; second class lower, 2.5–2.99; third class, 2.0–2.49; pass, 1.5–1.99; and fail, 0–1.49). A test for normality showed an approximately normal distribution of CGPA and therefore was not transformed for the analysis performed. The variables were described using frequencies and percentages. Univariable associations between the independent variables in the study and licensure were tested with chi-square/Fischer’s exact while associations with CGPA were tested with one-way analysis of variance (ANOVA). A logistic regression model was fitted to further look at the relationship between CGPA, sociodemographic characteristics, and previous education on the odds of passing the licensure examinations. The variables considered in the model (based on preknowledge of their relationship with students performance) were gender, age, home community, entry category into nursing (Senior Secondary School Certificate Examination, West African Senior School Certificate Examination or mature), course followed at high school (general science or other), high school ownership (government owned or other), academic standard of high school, and career choice of nursing programme (first, second, third, or fourth). All statistical significances were tested at
The ethical consideration of confidentiality was strictly upheld in this study. This was done through protection of the privacy of the students by not revealing their identities. The necessary permission was also obtained from ethics committees of selected institutions. Informed consent was sought from prospective study participants. The research protocol was further subjected to review and approval by the Committee for Human Research Publication and Ethics (CHRPE) of KNUST/KATH. Information gathered from participants was kept in a safe place to further ensure confidentiality.
Table
Description of background characteristics and previous education.
Variable |
|
Percentage |
---|---|---|
Gender | ||
Male | 77 | 43.7 |
Female | 99 | 56.3 |
Age | ||
21–25 | 6 | 3.4 |
26–30 | 152 | 86.4 |
31–35 | 18 | 10.2 |
Christian religion | 162 | 92.0 |
Description of home community | ||
Rural | 20 | 11.4 |
Semiurban | 92 | 52.2 |
City/urban | 64 | 36.4 |
Mother education | ||
Non | 25 | 14.2 |
Basic | 81 | 46.0 |
Secondary | 42 | 23.9 |
Tertiary | 28 | 15.9 |
Father education | ||
Non | 7 | 4.0 |
Basic | 41 | 23.2 |
Secondary | 52 | 29.5 |
Tertiary | 76 | 43.2 |
Mother health worker | 6 | 3.4 |
Father health worker | 5 | 2.8 |
Entry category into nursing programme | ||
SSSCE | 14 | 8.0 |
WASSCE | 156 | 88.6 |
Mature | 6 | 3.4 |
Course read during high school education | ||
General science | 67 | 38.1 |
General arts | 83 | 47.2 |
Home economics | 22 | 12.5 |
Agricultural science | 4 | 2.3 |
Former school | ||
Government owned | 129 | 73.3 |
Mission | 29 | 16.5 |
Private/other | 18 | 10.2 |
Former school was located in urban setting | 121 | 68.6 |
Former school has high academic status | 120 | 68.2 |
Nursing as a career of choice | ||
First | 118 | 67.0 |
Second | 41 | 23.3 |
Third/fourth | 17 | 9.7 |
Most of the students (88.6%) entered the nursing training with a West African Senior School Certificate Examination (WASSCE) qualification whereas only 2.3% entered as mature students. About 38% read general science and 47.2% read general arts whereas 12.5% read home economics. Majority of the students entered the nursing training from government owned institutions (73.3%) whereas 16.5% and 10.2% were from mission and private institutions, respectively. Majority of the students described their former schools as in urban setting (68.6%) and had high academic status (68.2%). One hundred and eighteen students constituting 67% chose nursing first whereas it was second choice for 23.3% of the students. Only 3.4% and 2.8% of respondents’ mothers and fathers were health workers, respectively.
The students had diverse motivations for choosing the nursing profession. This was assessed with a multiple response question and the most cited reason by the students was “always wanted to be a professional nurse,” 55.1%. Having the desire to help others was the second (49.1%) and third most cited reason for pursuing the nursing profession was opportunity of getting job offer after completion, 21%. Other reasons included seeing the nursing as a secure job (25%), availability of students’ allowances (8%) and exposure to family and friends in healthcare profession (7.4%).
As shown in Table
Relationship between school performance and licensure examination.
School performance | Licensure examination | Total |
|
|
---|---|---|---|---|
Passed |
Failed |
|||
Mean CGPA, mean (SD) | 2.98 ± 0.37 | 2.63 ± 0.22 | 2.89 ± 0.37 | <0.001 |
CGPA, |
||||
First class (3.6–4.0) | 11 (100.0) | 0 (0.0) | 11 (6.3) | <0.001 |
Second class upper (3.0–3.59) | 53 (96.4) | 2 (3.6) | 55 (31.2) | |
Second class lower (2.5–2.99) | 55 (64.0) | 31 (36.0) | 86 (48.9) | |
Third class (2.0–2.49) | 11 (45.8) | 13 (54.2) | 24 (13.6) | |
Total | 130 (73.9) | 46 (26.1) |
The CGPA of the students was significantly associated with the performance in the licensure examinations with the mean CGPA being higher among those who passed the licensure examination as compared to those who failed (2.98 versus 2.63;
Table
Influence of sociodemographic characteristics on performance in licensure examinations.
Variable | Licensure exam |
|
Mean CGPA |
|
---|---|---|---|---|
Gender | ||||
Male | 76.6 | 0.288 | 2.9 (0.4) | 0.451 |
Female | 71.7 | 2.9 (0.4) | ||
Age | ||||
21–25 | 50.0 | 0.180 | 2.7 (0.2) | 0.361 |
26–30 | 76.3 | 2.9 (0.4) | ||
31–35 | 61.1 | 2.8 (0.4) | ||
Christian religion | 72.8 | 0.210 | 2.9 (0.4) | 0.143 |
Description of home community | ||||
Rural | 70.0 | 0.919 | 2.8 (0.3) | 0.062 |
Semiurban | 75.0 | 2.9 (0.4) | ||
City/urban | 73.0 | 2.9 (0.4) | ||
Mother’s education | ||||
Non | 72.0 | 0.917 | 2.9 (0.3) | 0.078 |
Basic | 74.1 | 2.9 (0.4) | ||
Secondary | 71.4 | 2.9 (0.4) | ||
Tertiary | 78.6 | 2.9 (0.4) | ||
Father’s education | ||||
Non | 71.4 | 0.796 | 2.8 (0.3) | 0.395 |
Basic | 78.0 | 2.8 (0.3) | ||
Secondary | 69.2 | 2.9 (0.3) | ||
Tertiary | 75.0 | 2.9 (0.4) |
As shown in Table
Influence of previous education on students’ performance.
Variables | Licensure exams |
|
Mean CGPA |
|
---|---|---|---|---|
% passed | ||||
Entry category into nursing programme | ||||
SSSCE | 71.4 | 0.474 | 2.82 (0.4) | 0.655 |
WASSCE | 73.1 | 2.90 (0.4) | ||
Mature | 100.0 | 2.74 (0.3) | ||
Course read during high school education | ||||
General science | 76.1 | 0.491 | 2.89 (0.4) | 0.828 |
General arts | 73.5 | 2.89 (0.4) | ||
Home economics | 63.6 | 2.88 (0.4) | ||
Agricultural science | 75.0 | 3.06 (0.6) | ||
Former school was | ||||
Government owned | 76.7 | 0.352 | 2.93 (0.4) | 0.026 |
Mission | 65.5 | 2.78 (0.4) | ||
Private/other | 66.7 | 2.74 (0.3) | ||
Former school was located in urban setting | ||||
Agree | 77.7 | 0.087 | 2.92 (0.4) | 0.460 |
Disagree | 65.5 | 2.85 (0.4) | ||
Former school has high academic status | ||||
Agree | 75.8 | 0.364 | 2.90 (0.4) | 0.147 |
Disagree | 69.6 | 2.91 (0.3) | ||
Nursing as a career of choice | ||||
First | 72.9 | 0.801 | 2.87 (0.4) | 0.715 |
Second | 78.0 | 2.93 (0.4) | ||
Third/fourth | 70.6 | 2.89 (0.4) |
In the multivariable analysis, CGPA had strong positive relationship with performance in licensure examinations after adjusting for the sociodemographic characteristics and previous education (AOR = 15.27; 95% CI = 6.28, 27.11). Age, gender, home residence, entering nursing training with WASSCE, parental education, nursing being a first choice career of choice, and reading science in formal school were entered in the model. As shown in Table
Logistic regression analysis of influence of entry characteristics on performance in licensing examinations.
Variable | Adjusted odds ratio (95% CI) | SE |
---|---|---|
CGPA | 15.27 [6.28, 27.11] |
0.88 |
Age <30 years | 0.31 [0.06, 1.63] | 0.85 |
Male gender | 1.13 [0.50, 2.55] | 0.42 |
Home residence (ref = rural) | ||
Semiurban | 1.49 [0.41, 5.37] | 0.65 |
City/urban | 1.44 [0.38, 5.42] | 0.68 |
Father highly educated | 0.56 [0.21, 1.49] | 0.49 |
Mother highly education | 1.23 [0.55, 2.76] | 0.41 |
Entered nursing with WASSCE | 0.32 [0.04, 2.63] | 1.08 |
Nursing was a first career of choice | 0.50 [0.21, 1.19] | 0.45 |
Read science in formal school | 1.2 [0.5, 2.6] | 0.40 |
Nursing education should be taken as an important aspect of healthcare provision, by ensuring nurses with the right training and characters are produced to provide the necessary healthcare. Writing and passing the licensure examination is required for registration and practice as a nurse. This study sought to investigate the relationship between school performance and licensure examinations. Finding from this study shows a very strong positive relationship between school CGPA and performance in the licensure examinations. This is supported by studies from Stewart et al. [
While NCLEX-RN examination is designed to identify candidates who possess the theoretical knowledge to practice safely as an entry-level nurse, NLE measures nursing students’ academic outcomes and practical skills. The current study therefore extends the existing evidence (strong correlation between academic success and prior academic achievement) to include an association between students’ previous achievement and their psychomotor skills. Future studies must however explore the content validity of nursing licensing examinations. This will ensure that nurses not only are competent academically but also possess some additional professional qualities.
Nonacademic or demographic characteristics of students have been cited as important variables in predicting academic performance of the students [
Contrary to previous research, the study did not find any association between age, gender, and academic performance of the students [
This study found no influence of parents’ education on performance in the licensure examinations. This is inconsistent to other previous studies, which found parental education as well as employment background as important factor that significantly affects students’ academic success [
This study again looked at previous academic programme in senior high school and entry category and how these influence performance in licensure examinations. The differences in performance in licensure examinations with respect to previous course at the senior high school could not reach significant levels. Findings from this study suggest that the students course offered at previous educational level and the entry level characteristics may not play an important role in determining the students success in the licensure examination although previous studies have found a significant relationship. Potolsky et al. [
This study might however suffer some methodological limitations. The inability to include all or majority of the nursing institutions in the country could influence the generalizability of these study findings. This study is generalizable to the Kumasi metropolis only. It is however assumed that characteristics of students in nursing training institutions do not differ much across the region. The study might have also left out other important characteristics that could influence performance of nursing students in the licensure examinations.
The findings of this study suggest that students’ previous education and demographic characteristics do not play a role in their performance in the licensure examinations. This further indicates that other school levels as well as tutor factors and issues relating to the programme may better explain the differences in outcome with respect to the licensure examinations. It is recommended that a multilevel study be conducted to explore other factors such as availability of academic resources to enhance learning, students perceptions of the nursing programme, tutors motivation, and students study skills, thinking abilities, and time management. It is further recommended that this study be conducted with the inclusion of other nursing institutions in the region to have a deeper insight into the subject matter. The study however indicates that the school performance of the schools is a good predictor of their performance in the licensure examinations. Efforts to improve students learning and outcome at the school level should therefore be promoted. However, students having a prior notice of school performance as criteria for being selected for licensure examinations could encourage them to put much effort in their study.
The authors declare that they have no competing interests in the submission of this paper.
The authors express their profound gratitude to Daniel Attah-Tuffour and Omono Asamoah, Principals of SDA Nursing Midwifery Nursing Training College and Kumasi Nursing and Midwifery Training Colleges, respectively, for granting them permission to use their facility respective information. The authors also acknowledge the efforts of the research assistants involved in the study as well as all students who participated in this study.