Saudi Journal for Health Sciences

: 2022  |  Volume : 11  |  Issue : 3  |  Page : 184--189

The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: A quasi-experimental study

Abdulaziz Mofdy Almarwani 
 Department of Psychiatric Nursing, College of Nursing, Taibah University, Medina, Saudi Arabia

Correspondence Address:
Abdulaziz Mofdy Almarwani
Department of Psychiatric Nursing, College of Nursing, Taibah University, Medina, Saudi Arabia Janadah 20 Bin Umayyah Road, Medina 42353
Saudi Arabia


Background: Nursing licensure examinations (NLEs) are used worldwide to determine nursing students' levels of competence and preparedness to practice nursing. However, despite students' knowledge of nursing concepts, some students struggle with anxiety, pressure, and NLE question style. Preparation courses embedded within nursing students' curriculum may be effective in preparing students to take the NLE. Aim: The aim is to determine the effectiveness of implementing a Saudi Nursing Licensure Examination (SNLE) preparation course into nursing students' curriculum. Setting and Design: A quasi-experimental, repeated measures design was used with 109 undergraduate nursing students in three-branch college of nursing in the western region of Saudi Arabia. Methods: Students completed a 3-month SNLE preparation course integrated into the current curriculum. The course involved practice question preparation, case studies, and online learning videos. Students took an SNLE-style pretest before the course and a posttest one month after the course was completed. Results: Most students were female (70.6%) and 34.9% reported studying 1–2 h per week studying for the course. There was a significant, positive, and strong correlation between the number of hours spent studying and SNLE posttest scores (r = 0.729, n = 109, P < 0.001). Students performed significantly better after taking the SNLE preparation course. Female students scored higher in all domains compared to male students, especially within the maternity and pediatric nursing domain. Conclusions: An NLE preparation course integrated into the nursing curriculum was shown to be effective within this sample of Saudi nursing students. Further research with larger samples may be needed to corroborate these findings.

How to cite this article:
Almarwani AM. The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: A quasi-experimental study.Saudi J Health Sci 2022;11:184-189

How to cite this URL:
Almarwani AM. The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: A quasi-experimental study. Saudi J Health Sci [serial online] 2022 [cited 2023 Feb 7 ];11:184-189
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Globally, nurses represent more than 50% of providers working in the health-care field.[1] The demand for nurses is increasing, and nursing education programs must adapt to this demand by preparing more qualified nurses.[2],[3] After completing program requirements, nursing students must be evaluated and successfully achieve nursing competencies to ensure they can practice safely by taking a nursing licensure examination (NLE).[4]

NLE passing rates are important indicators of nursing education quality and preparation for students, faculty, and nursing programs overall.[5] Therefore, it is crucial that nursing students are well-prepared with the knowledge and skills required to pass the NLE and provide competent nursing care. Most countries have similarities regarding the purpose of the NLE, which is to prepare a competent nurse for the field before actual practice. However, the variation is only linked to the NLE names. For example, students in the United States (U. S.) and Canada must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN),[6] and in China, students take the National Nursing Licensure Examination.[7] Indonesian nursing students must take the Indonesian Nurse Competency Examination,[8] and in Saudi Arabia, students are required to take the Saudi Nursing Licensure Examination (SNLE).[9],[10] The SNLE is required by the Saudi Commission for Health Specialties, which is the scientific commission responsible for regulating and controlling specialist certifications.[9]

The purpose of the SNLE is to examine nursing students' readiness to work in the health-care field and provide direct patient care.[11] During the examination, nursing students will spend three hours answering 150 multiple-choice questions.[11] For each question, nursing students must select the best response out of four possible answers. The SNLE includes recollection questions to measure nursing students' knowledge and scenario-based questions to test their abilities in interpretation, analysis, decision-making, reasoning, and problem-solving skills.[5] The SNLE focuses on several domains, including adult nursing, maternity and pediatric nursing, psychiatric nursing, and nursing research, as they are considered the core of the nursing practice.[11]

In 2021, 85% of Saudi nursing students passed the SNLE on the first attempt.[12] Greater efforts need to be made to improve first-time SNLE pass rates by preparing students on how to take the examination.[5],[13] One promising strategy to help prepare students for the SNLE is to implement an examination preparation course into the nursing curriculum.

Preparing nursing students for the Saudi nurse licensure examination

In Saudi Arabia, limited studies have been conducted that aim to implement and assess the effectiveness of an SNLE preparation course. In one study, Alharbi (2021) examined the effectiveness of an SNLE enhancement program in the educational domain of critical care. The study compared the results of the pre- and post-test examinations, which revealed that the SNLE enhancement program improved nursing student performance and examination scores.[5] However, this study was limited to critical care nursing concepts and no other domains of nursing, and the sample of that study was collected from one nursing college; therefore, their results may not be generalizable to other settings.

To the best of our knowledge, no studies have assessed the effectiveness of implementing a comprehensive, multi-domain SNLE preparation course. Therefore, the purpose of this study was to examine the effectiveness of a 3-month SNLE preparation course in four essential SNLE domains: adult nursing, maternity and pediatric nursing, psychiatric nursing, and nursing research. The study aimed to answer the following questions:

What is the effect of the implementation of the SNLE preparation course on nursing students' competence in the four SNLE domains?What is the relationship between hours spent studying and SNLE posttest scores?Are there any statistically significant differences between students' gender and the four nursing domains scores?

Theoretical framework

Malcolm Knowles' theory of andragogy was used as a study theoretical framework to guide the SNLE preparation course.[14] This theory proposed that there are six assumptions of adult learners. First, students need to know why they are learning something before beginning to learn it.[14] After reviewing course outlines, students in the SNLE preparation course the purpose of the course and its role in preparing them for the SNLE. Second, as students' progress in their education program, they develop a more independent self-concept, which allows them to have a sense of control over their learning.[14] Most of the time spent on the SNLE preparation course required students to be an independent learner. Third, students' learning is informed by prior experiences, and the SNLE preparation course was comprised of content covered in courses taken in prior semesters. Fourth, students become ready to learn what they need to know to be successful.[14] The SNLE preparation course was designed to help 4th year nursing students become ready to take and successfully pass the SNLE. The fifth and sixth assumptions are rooted in motivation; students are motivated to learn to the extent that they believe learning will help them perform tasks or handle problems, with intrinsic motivation being more powerful than extrinsic motivation.[14] Students were intrinsically motivated to take the SNLE preparation course since it was preparing them for success on the SNLE, which is necessary to practice as a nurse.


Study design and sample

A single group, quasi-experimental repeated measures design was used. This study used a convenience sample of nursing students from three branches of a large public university in the western region of Saudi Arabia. The sample size was estimated using G-Power. Parameters applied to estimate the sample size include effect size (f2) =0.25; alpha = 0.05; power = 0.80. The total sample size needed based on this approach is 95 participants. To consider the attrition rate, the sample was increased by 10%.

Study intervention (Saudi Nursing Licensure Examination preparation course)

The SNLE preparation course aimed to familiarize students with the format of the SNLE, enhance their ability to answer questions on the SNLE, and learn how to manage their time studying for the SNLE. At the beginning of the course, students were divided into ten groups, with 12–15 students per group. The course lasted 10 weeks, and students met online 1 day each week with nursing instructors. Nursing instructors varied from week to week based on their expertise and specialties. [Table 1] presents topics that were covered during the 10-week course. Each group was asked to search for 50 NCLEX-RN-style questions covering each of the four domains and present them weekly. Questions on the NCLEX-RN and SNLE are very similar; however, there are no reliable SNLE preparation resources widely available. Therefore, students were asked to use NCLEX-RN materials and questions as part of the SNLE preparation course. Students worked together using NCLEX-RN preparation books and online resources to identify their questions. By the end of the course, students had presented over 500 questions and their correct answers.{Table 1}

The course included online activities, case studies, and online learning videos that aimed to prepare students and motivate them toward passing the SNLE. For example, students were given a list of videos to watch with topics including nursing roles in Saudi Arabia, the importance of the SNLE, the process of applying for the SNLE, and strategies to answer SNLE questions including prioritization skills. Each week, the faculty discussed at least one case study to help develop critical thinking and decision-making. Students were also asked to submit reflective journals during the 4-month course.

Data collection

Students completed an online pretest containing 150 SNLE-style questions before the preparation course. The College of Nursing faculty developed the SNLE-style multiple choice test. The questions were categorized into four domains based on the SNLE guidelines [Table 2]. Each of the 150 SNLE styles was worth one point, and the higher the Student's scores, the better their grades. The Cronbach's alpha of SNLE domains ranged from 0.81 to 0.98. One month after completing the course, a new link was sent to students containing the same 150 questions but re-randomized (posttest).{Table 2}

Data analysis

The Statistical Package for the Social Sciences (SPSS) version 28 released by IBM Corp, (Armonk, NY, USA) was used to analyze study data. Descriptive statistics, including mean, standard deviation (SD), and frequencies, were used to describe the characteristics of participants. Paired sample t-test, Pearson's correlation coefficients, and one-way analysis of variance were used to determine differences in students' scores and study variables. The assumptions of the parametric test were tested before conducting the analysis. None of the primary or secondary assumptions were violated.

Ethical considerations

Ethical approval was obtained from the College of Nursing at Taibah University. Students were informed that their participation in the study was voluntary and that they had the right to withdraw at any time during the course. Furthermore, participants were informed that their participation is anonymous, and they will not be asked for any identifiable information. The first page of the test contains the informed consent. Students could not start the test unless they agreed to the informed consent.


A total of 109 students completed the pre- and post-SNLE-style test [Table 3]. The majority of study participants were female (70.6%), and most students attended University Branch one (67.9%). About 35%, the highest percentage reported by students, spent 1–2 h per week studying for the SNLE and answering practice questions.{Table 3}

Effect of the Saudi nursing licensure examination preparation course on posttest scores

Nursing students scored significantly higher on the posttest examination than on the pretest examination [Table 4]. The paired sample t-test revealed a significant difference in the mean of the SNLE test before (M = 68.9, SD = 24.6) and after the SNLE course (M = 106.0, SD = 16.1; t [108) = −18.3, P < 0.05). Female students scored significantly higher than males in both the pretest (M = 74.2, SD = 25.4) and the posttest (M = 110, SD = 15.3; F [1,107) =303, P < 0.001). All nursing domains significantly improved after completing the SNLE course [Table 4].{Table 4}

There was a significant, positive, and strong correlation between time spent studying and scores on the SNLE posttest (r = 0.729, n = 109, P < 0.001). For example, nursing students who spent 6–7 h per week studying for the SNLE scored higher in their posttest (M = 116, SD = 11.6) as compared to students who 1–2 h per week [M = 93.2, SD = 11.9; [Table 4]].

All nursing students from the three university branches scored higher on the posttest compared to pretest [Table 4]. For Branch 1, the paired sample t-test revealed a statistically significant difference in the mean SNLE test score before (M = 67.0, SD = 24.1) and after the preparation course (M = 106, SD = 16.4; t [73) = −15.4, P < 0.05). In Branch 2, the paired sample t-test revealed a statistically significant difference in the mean SNLE test score before (M = 77.1, SD = 23.6) and after the course (M = 110, SD = 15.0; t [21] = −7.06, P < 0.05). Among Branch 3 students, the paired sample t-test also revealed a statistically significant difference in the mean SNLE test score before (M = 65.3, SD = 27.3) and after the course (M = 105, SD = 16.3; t [12] = −6.92, P < 0.05). There were no significant differences among university branches.

Analysis of variance for nursing students based on gender

Female nursing students scored higher in all domains than male nursing students [Table 5]. The adult nursing domain results were found to be insignificant for pretest (F[1107) =3.25, P = 0.074) and posttest (F [1,107) =0.669, P = 0.415). For test scores in maternity and pediatric domain, the results indicate that males scored significantly lower than female students in both the pretest (F [1,107) =15.3, P < 0.001) and posttest (F [1,107) =27.2, P < 0.001). Females scored significantly higher on the psychiatric nursing domain of the pretest (F [1,107) =4.82, P = 0.030), whereas statistically insignificant differences were found in posttest scores (F [1,107) =0.076, P = 0.783). Finally, there were no significant differences found between males and females in the research domain on both the pretest (F [1,107) =2.75, P = 0.100) and posttest (F [1,107) =0.644, P = 0.424).{Table 5}


Passing a nursing licensure examination is an important benchmark in nursing students' careers and determines whether a student is capable of competently providing patient care. Therefore, preparedness for these exams is critical. Implementing preparation programs into the nursing curriculum, like the SNLE preparation course described in this paper, may be a feasible and effective strategy for promoting nursing students' readiness for the licensure examination and clinical practice. This was the first study to the author's knowledge assessing the effectiveness of implementing an SNLE preparation course into the curriculum of 4th year nursing students.

After the implementation of this course, scores on the SNLE posttest increased significantly. The pretest evaluation indicated low SNLE scores, especially among male nursing students. These findings are concurrent with a study conducted by Wan Chik et al. (2012), where male nursing students reported lower academic performance than female nursing students as measured by their GPA.[15] In addition, Gu and Sok (2021) reported that female nursing students have higher academic achievement than male students.[16] Students' perspective of their ability and motivation toward nursing could play a role in their academic achievement.[17] According to Carlsson (2019), female nursing students perceive themselves as more competent in nursing care than male students.[18] Maurud et al.(2022) reported that male nursing students are less motivated in choosing a nursing specialty than female nursing students.[19]

Female nursing students scored significantly higher in the pre- and post-SNLE test than males, especially in the maternity and pediatric domain, which can likely be explained by cultural influence. For example, male nurses in Saudi Arabia received less practical experience in maternity nursing than females due to religious and cultural barriers.[20] They may also face gender bias working in maternity departments.[21] Furthermore, male nursing students scoring low in the pretest of the maternity and pediatric domain might be due to a lack of effective delivery of maternity and pediatric courses within the curriculum. Male students in the current study did not receive clinical hospital experience in maternity nursing, and most of the clinical skills were demonstrated in laboratory settings. Therefore, greater attention may need to be given to enhance male nursing students' competencies in maternity content. The high fidelity simulation training was effective in improving male nurse's maternity practical competencies.[22]

One important factor identified in the study is the number of hours students spent studying for the SNLE. The findings suggest a positive and strong correlation between nursing students' time spent studying and their posttest score. Therefore, in addition to the faculty-delivered course, it is critical for nursing students to spend time studying independently. Finally, three different branches within the same university were compared. The majority of students were located at Branch one (main campus). All branches showed improvements from pre- to post-test with no statistical differences among them, indicating that students at all branches benefitted from the course.

Study strength and limitations

The study is considered among the first to examine the effectiveness of integrating SNLE courses into the nursing curricula. The study design allowed comparability between students' scores before and after completing the SNLE course, providing valuable information to future nurse educators and educational policymakers. The course length provided flexible time for students to learn and practice different SNLE question styles. The course allowed students to gain the necessary knowledge and skills to answer SNLE questions, increasing their chance of passing the SNLE examination the first time and increasing their readiness to practice nursing safely.

The convenience sample utilized in this study may have restricted the generalizability of the results to other similar population due to potential bias. Participants in the study were limited to three branches single Saudi university. Because the education course was held online due to the COVID-19 pandemic, researchers may have had a lack of control over students' attention to all components of the program. Although the study provided important information about the effectiveness of an SNLE preparation course, the researcher was not able to measure this cohort of students' NLE pass rates.


Nursing programs must ensure that their students are sufficiently prepared for practice while maintaining high NLE pass rates. However, even if students are well-prepared, they may struggle with anxiety associated with taking a licensure examination and be unfamiliar with its layout and question style. Improving nursing students' confidence in their abilities to pass the NLE is an essential role of nurse educators. Students' lack of confidence has been identified as one of the major reasons for nursing students delaying their examinations.[23] Therefore, it is recommended that nurse educators provide their students with adequate preparation to familiarize them with the NLE structure and style, as well as encourage students to sit for the NLE as early as they are eligible.

Cultural and religious barriers may hinder Saudi male students' knowledge and competency in maternity and pediatric nursing, so nursing programs must pay special attention to improving male students' competencies in these. Finally, future research with long-term follow-up measuring nursing students' NLE passes may provide additional evidence of the effectiveness of implementing NLE preparation courses into the nursing curriculum.


The researcher would like to acknowledge nursing students for participating in this study. The researcher would like to express sincere appreciation and deepest gratitude to those faculty who participated in the weekly presentation and those who prepared the SNLE questions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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