“Outcomes are a distraction.” —Nick Saban
Is Nick Saban, the six-time national title-winning coach at Alabama, actually saying that a national championship is a distraction? Yes. That’s exactly what he’s saying. And if he was a nurse, he’d add NCLEX and certification exams to that list. The NGN question formats, too.
When you understand quality, you understand that outcomes don’t just happen because you think about them. Even if you’re obsessive about the outcome—and many nursing programs are obsessed with NCLEX pass rates—you don’t achieve high NCLEX pass rates by focusing on that. You make sure you have the structures and processes in place to get you there.
Donabedian Said It First
Donabedian published his quality framework in 1966. He organized quality in healthcare into three domains: structure, process, and outcome.
The structures are what you have. The right equipment, adequate staffing, the right clinical environment. The processes are what you do with it: the workflows, the clinical decisions, the teaching methods. The outcome is what follows.
His insight wasn’t that outcomes matter. Everyone already knew that. His insight was that outcomes are the wrong thing to manage directly. You can’t pull the outcome lever and make great outcomes happen. You can only pull the structure lever and the process lever, and then observe what follows. When the outcome isn’t what you wanted, you go back and find the structure or process that produced it.
That distinction changes how you diagnose every quality problem.
What NCLEX Pass Rates Actually Tell You
Nursing programs are measured on NCLEX pass rates, and most of them manage that metric as if passing NCLEX is the thing they’re trying to produce. We’re not. We’re trying to produce excellent nurses. But the pass rate shows up on the website, in accreditation documents, in faculty retreats.
The NCLEX pass rate is an outcome. Managing it directly doesn’t work.
What the rate actually reflects is everything that happened upstream: the curriculum design, the clinical preparation, the quality of assessments faculty used to catch students who were struggling before boards. If the pass rate is low, the answer isn’t to bolt an NCLEX prep course onto the end of the program. That’s grabbing the outcome lever. The problem is in the structures and processes, and that’s where the fix has to go.
NCLEX prep courses work at the margins. A student with solid foundational knowledge who hasn’t seen the question format will improve her score with focused prep. A student who doesn’t have the foundational knowledge won’t. Programs that lead with NCLEX prep as their primary strategy have confused the outcome for a cause.
The NGN Is Not the Problem Either
The Next Generation NCLEX has been treated as a curriculum crisis by programs that were already watching the wrong thing. The format changed. The test now emphasizes clinical judgment over recall. Programs are redesigning syllabi around the new formats, buying prep materials targeted at NGN question types, holding faculty workshops on writing NGN cases.
That’s not wrong. But updating the question format isn’t the same as rebuilding the reasoning that the format is trying to test.
Students who struggle with NGN questions struggle because clinical judgment isn’t built yet, not because they haven’t seen enough case studies in the NGN format. You can teach format recognition. You can’t substitute it for reasoning. An NP student who has done 50 supervised patient encounters, gotten corrected mid-assessment, and seen the same presentation come in looking different the second time has something a case study bank can’t give her. The format is a surface feature. The reasoning is the structure underneath it.
What I Tell My Students
I teach the graduate ACNP program at Saint Joseph’s University. I tell my students to put their certification exams out of mind. (I’m sure they do just that!) Not because passing doesn’t matter. Because thinking about passing doesn’t move them toward it.
I assume they’ll pass. Not magical thinking. If the structures and processes we put in place do what they’re supposed to do, the exam outcome follows. When someone in the cohort is struggling, the conversation is never “how do we get you through the boards?” It’s “what’s happening with the clinical reasoning?” Reasoning is the process. The exam is the outcome. Fix what you can fix.
That’s why I’m skeptical of board prep tools that teach people to recognize answer patterns without building the reasoning underneath. Pattern recognition has some value at the margins. But the reasoning has to be there first. What I’ve been building at Advanced Practice Ready works from the other direction: assessments that find the gaps in the clinical reasoning, not just gaps in test-taking strategy.
Saban called the national championship a distraction because nobody controls outcomes directly. But you can control the structures and processes: the coaching staff and playbook, practice intensity and game day rituals. Faculty and curriculum. Sim lab and clinical experiences.
Programs watching board pass rates are staring at the trophy. The work is in what they built before anyone sat down to test: the curriculum, the clinical preparation, the question quality, the feedback students got when they were wrong, and the relationships with faculty.
Donabedian said that in 1966. Saban lived it every season for a decade at Alabama. Nursing education is still arguing about the trophy.