As a health care educator and patient advocate on the one hand, and a retired nurse on the other, the authors regularly correspond with doctors, nurses, and nurse practitioners. Richard Lawhern is a nationally recognized subject matter expert on pain management. Debra Lewis is a retired nurse who shares stories here of some of the nurses who were referred to her for tutoring after graduating from nursing school but failing their state boards. For some years, she worked as an instructor/tutor with such people. Imagine Debra’s horror when encountering graduated RNs or BSNs who told her stories like these during the five years that she successfully coached others:
- One newly graduated nurse asked, “How many milligrams in a gram?” because she honestly didn’t know.
- Another had never given an injection without supervision.
- Yet a third nurse was unable to accurately read a basic EKG rhythm strip.
- A fourth had no idea how to do a blood pressure check with a sphygmomanometer.
These stories prompted us to research the failure rates in state nursing boards. The numbers are chilling, as are the reasons behind them. For U.S.-educated graduating registered nurses (RNs), the national first-time failure rate on the state board licensing exam (the NCLEX-RN) is roughly 13 percent to 15 percent based on recent annual data from the National Council of State Boards of Nursing (NCSBN). Graduates from Bachelor of Science in Nursing (BSN) programs typically experience slightly lower failure rates (around 9 percent to 10 percent) compared to Associate Degree in Nursing (ADN) graduates (around 12 percent to 14 percent).
However, first-time national averages do not tell the whole story. Failure rates spike dramatically for second-time or repeat test-takers (45 percent to 50 percent). Likewise, failure rates in Alaska (22 percent), Florida (17.8 percent), and New York (15.2 percent) substantially exceed national averages. By contrast, rates in the best states drop as low as 5 percent.
As revealed by an AI-based large language model search below, failure rates are primarily sensitive to state standards. “Each state has its own board of nursing that sets the rules for operating a nursing program. This is the single biggest factor in failure rate variations.
- Strict states (low failure rates): States like California, Texas, and Oregon have strict rules. If a nursing school’s first-time pass rate drops below 80 percent or 85 percent for two years in a row, the state will put the school on probation or shut it down. This forces schools to maintain high standards.
- Lax states (high failure rates): States like Florida historically passed laws that made it much easier to open private, for-profit nursing schools with very little government oversight. This led to a surge in low-quality programs that graduated students who were completely unprepared for the state boards.”
Admission standards and “gatekeeping”
Nursing programs in different states select and filter their students differently:
- Highly competitive programs: In states with limited nursing school slots, schools only accept students with top GPAs and high entrance exam scores. These students are statistically much more likely to pass the NCLEX on their first try.
- Open enrollment programs: Programs that accept almost any paying applicant often struggle with high failure rates.
- Graduation barriers: Some strict schools use difficult “exit exams” (like the HESI or ATI test). If a student cannot pass the exit exam, the school will not let them graduate. This stops struggling students from ever taking the NCLEX, which artificially keeps the school’s official failure rate very low.
If you are a clinical patient who anticipates a hospital stay or even an outpatient visit, these statistics are directly pertinent. For the most part, the state board process eliminates nursing candidates who lack basic preparation and knowledge. However, we must also acknowledge that in our younger nurses and clinical staff, excessive exposure to social media contributes to poorer learning and preparation.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Medical and nursing training requires intense focus, deep reading, and high-stakes critical thinking. Heavy social media use directly disrupts these learning patterns. However, the impact is a double-edged sword: while personal, recreational browsing actively hurts preparation, intentional use for academic or clinical collaboration can actually help students and practitioners.
As one of the authors once shared with an RN during a late-night hospital visit, “A doctor can diagnose clinical issues and develop a treatment plan. But in the small hours of the morning, if a medical emergency occurs, it will be a nurse who saves your life.”
Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment. Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.
Debra Lewis is a nurse.
