Development of an Online Question Bank for Midwifery and Women's Health Nurse Practitioner Comprehensive and Certification Examination Preparation

Pass rates on national certification examinations (NCEs) vary by health care profession and specialty.^1-3 Pass rates serve as critical indicators for both the student and the graduate education program. Improving pass rates is a challenge because ensuring examination success requires not only quality education, but critical thinking and test-taking skills. There is extensive research indicating that well-designed practice tests can serve as valuable tools in preparing for health care professional NCEs.^{4, 5}

Students of Accreditation Commission for Midwifery Education (ACME)-accredited midwifery and accredited women's health nurse practitioner (WHNP) education programs must successfully pass a comprehensive exam during their last term and meet program requirements to take the American Midwifery Certification Board (AMCB) and National Certification Corporation (NCC) WHNP NCEs, respectively, to become certified nurse-midwives/certified midwives (CNMs/CMs) or board certified WHNPs. AMCB overall certification pass rates have decreased from 91.8% in 2015 to 73.0% in 2024, and NCC WHNP overall certification pass rates have decreased from 94% in 2020 to 79.0% in 2024.^{1, 6, 7} Consistent with national trends, AMCB and NCC pass rates among graduates of one large, distance-based education program also decreased.

In response to the pass rate trend and a goal to bolster students’ confidence, readiness, and knowledge, program leadership identified a critical need for an additional study resource. Consequently, over the course of 2 years, nurse-midwifery and WHNP faculty developed an online question bank of 600 multiple choice (MC) questions titled the Review Portal. Practice review of MC questions has been found to be an effective study technique, assisting with recall and requiring active, engaged learning rather than passively absorbing information from textbooks.^{8, 9} The Review Portal was constructed in Canvas, a learning management system, and launched in 2018. It is a free resource to program students to assist with preparation for their comprehensive examinations and NCEs.

The design and development of the Review Portal was unique in many ways (see Table 1). First, to promote optimal review of midwifery content, the percentage of items was mapped to the AMCB examination proportionally by content area (see Table 2). It was not originally mapped to the NCC WHNP certification examination since pass rates among program graduates were higher on the NCC WHNP examination compared with the AMCB examination. However, except for intrapartum and newborn care, the content for both examinations is similar, so the resource was offered to students preparing for both examinations. Second, specific topics within each content area were determined using the AMCB and NCC WHNP Candidate Handbook blueprints.^{6, 10} Although the WHNP certification examination blueprint includes pharmacology and assessment, diagnostic testing, and interpretation content areas, the AMCB certification examination does not. Thus, these topics were integrated throughout. Third, within each content area, item types were mapped to the AMCB examination with respect to normalcy and difficulty (Table 2). This increased the rigor of the resource, with two-thirds of the questions assessing clinical judgment over knowledge. Fourth, items included 4 answer choices (see Table 3), similar to the AMCB examination and based on psychometric literature recommendations.¹¹ Fifth, each item contains a rationale as to why the correct answer was correct and why the incorrect answer was incorrect. Additionally, each rationale is validated with an evidence-based resource to promote further review. Referenced textbooks were among those listed in the AMCB Candidate Handbook.⁶ Finally, to promote optimal student outcomes, the item writing process was held to a high standard. A nationally recognized leader in item writing (and member of the faculty) provided training in writing a well-constructed MC question. Faculty members were responsible for writing items in their area of expertise. Each item underwent a rigorous review process using a writing accountability group model and was reviewed by at least 2 other faculty. At the end of the year, over 600 items were compiled.

In 2024, the Review Portal underwent an in-depth revision for a myriad of reasons. First, new editions were published of 4 highly regarded textbooks frequently used in midwifery and WHNP education.^12-15 Consequently, faculty revised the items’ stem, answers, rationale, and validation as indicated to capture the most up-to-date evidence. Second, consistent with American College of Nurse-Midwives core competencies and gender-inclusive language that accurately reflects the midwifery scope of practice, faculty revised the items and rationales to person-centered language. For example, use of the word woman was changed to person or individual, or the word cisgender or transgender was added to the word woman to read cisgender woman. Third, several gaps were addressed to promote adequate NCC WHNP certification examination preparation, including items on sexual and reproductive health care of sperm-producing individuals and professional issues. Finally, an additional 100 questions were written to address student performance gaps identified by program faculty in their specialty coursework. At the end of 2024, 700 questions were mapped to the AMCB certification examination with the most up-to-date evidence and inclusive of all WHNP certification examination content areas (see Table 2).

Since its launch in 2018, over 630 nurse-midwifery and WHNP students from one school have accessed the Review Portal to prepare for their comprehensive and NCEs. Student feedback has been overwhelmingly positive, reporting that it provides the essential structure and content to increase their examination confidence and readiness. Evaluation of the use of the Review Portal and correlated program pass rates are difficult to assess due to other curricular innovations implemented simultaneously to improve pass rates.

Given the dearth of resources with well-constructed, high-quantity MC items, rationales, and validations that support preparation for the AMCB and WHNP certification examinations on the market, faculty recognized the value in converting the Review Portal from Canvas to a printed and online textbook to benefit students from other programs. Proceeds from book sales are directed toward a student emergency fund to benefit our midwifery and WHNP students. As new evidence arises and knowledge gaps are identified, faculty will continue to revise and add items to the Review Portal to ensure accuracy and currency.

With falling national and program AMCB and NCC certification examination pass rates, additional examination resources are needed for midwifery and WHNP students. Through the development and implementation of an online question bank, students of one midwifery and WHNP education program are reporting an increase in their confidence and readiness for their comprehensive and certification examination(s). Although maintenance and expansion of a large question bank requires ongoing effort, a focus on supporting graduates as they prepare for the AMCB and NCC WHNP certification examinations is essential in order to diversify and grow the midwifery and WHNP workforce.

The authors have no conflicts of interest to disclose.