No Going Back: Should Pharmacy Exams Be One-Way Streets?

By: Shannon Dicken, PharmD and Jennifer Trujillo, PharmD, BCPS, FCCP, CDCES, BC-ADM

With declining NAPLEX pass rates over the past decade, PharmD programs are under pressure to revamp their curriculum and assessments to improve results. 

What are colleges of pharmacy implementing to combat this decline?  

• Required NAPLEX prep courses
• Brand/generic drug integration across courses
• Competency-based skills assessments 
• Practice exams mimicking the NAPLEX environment

While we await the evidence of their success, another emerging preparation strategy is sparking debate: disabling backward navigation in assessments to mirror NAPLEX and MPJE formats. In these exams, students face one question at a time—no going back, no second guessing. 

But here’s the real question:

Are we making evidence-based decisions by copying NAPLEX conditions in pharmacy education? Or are we simply hoping that borrowing the same navigation format will improve licensing exam scores?

NAPLEX History

The first “paper and pencil” pharmacy licensing exam, the NABPLEX, was converted to the NAPLEX in 1997: a computer-based, adaptive exam where backward navigation was disabled, as the candidate’s answer to one question impacted the presentation of future questions. In 2017, the computerized NAPLEX switched to a fixed, linear format. Though backward navigation could have been enabled, NABP kept the “one-pass only” rule without clear rationale. Today, the NAPLEX is a 225-question, 6-hour, computer-based fixed exam without backward navigation.

Time to Completion

Studies that assessed total time to completion with disabled backward navigation settings found a decrease in overall completion time on all assessments compared to when this function was enabled.^1-3 Even when the results were not statistically significant, the trend consistently showed faster exam completion times. While disabled backward navigation may improve efficiency in administering assessments, is this a meaningful measure of success in high-stakes assessments?

Student Performance

The impact of disabled navigation on exam scores is mixed. Two studies in colleges of pharmacy found no significant differences in average scores across multiple courses, though slight decreases were noted with disabled backward navigation.^1,4 In a study of a medical anatomy practical, results showed no significant score changes overall, but found lower performing students actually scored higher when backward navigation was allowed.² Another study evaluated the impact of disabled backward navigation on competency-based assessments, which required retakes until a minimum score is earned. Initial scores didn’t change much, but retake scores improved when backward navigation was disabled. Interestingly, more advanced students saw their first-attempt scores drop when navigation was disabled, but their retake scores stayed the same.³ The impact of disabled backward navigation may differ by student performance level and academic stage. Could this assessment strategy inadvertently widen the achievement gap?

Academic Integrity

Despite commentary and speculation, there is no published research on the impact of disabled backward navigation on academic dishonesty. Disabling backward navigation could decrease cheating on exams administered in a classroom or testing center environment as students would be unable to return to previous questions to change their selected answer based on the answer of a neighbor.^2,3 However, when students were asked if disabled backward navigation decreased academic dishonesty, the responses were split: half believed it did, and half didn’t.³ Those that didn’t even went so far as to say that students with intentions to cheat would find a way to do so whether backward navigation was disabled or not.³ If students believe that cheating is inevitable, are theorized assumptions the best solution to combat academic dishonesty?

Student Perceptions

Students overwhelmingly report that disabled backward navigation increases exam difficulty. At one institution, 74% of first-year students, 79% of second-year students, and 80% of third-year students agreed that disabled backward navigation made exams more difficult.³ Two separate studies assessed pharmacy and medical students’ test anxiety, both finding that the inability to return to questions during an exam heightened  test anxiety.^2,3 While a slight majority of surveyed pharmacy students agreed that this format better prepares them for the NAPLEX, most agreed that their preferred assessment format would allow backward navigation on exams.^2,3 Does disabling backward navigation actually prepare students for the NAPLEX, or does it instead increase stress, undermine confidence, and make multiple exams seem harder just to prepare them for one?

Discussion 

The decision to disable backward navigation should be driven by evidence, not emulation. While students generally prefer the ability to revisit questions, disabling backward navigation may improve exam flow and better simulate licensure conditions. That said, research on its impact on student performance, academic integrity, and NAPLEX preparation remains inconsistent.

Programs might consider a scaffolded approach. Introducing disabled navigation in later years or on low-stakes formative assessments could help students acclimate to NAPLEX-style testing without compromising performance or increasing anxiety. Future studies could explore how backward navigation affects formative versus summative assessments, and whether tailoring its use by student level shows significant differences.

Ultimately, it’s not just about simulating the NAPLEX. It’s about helping our students pass it. 

How will you rethink backward navigation to support student success?

References: 

1. Cochran GL, Foster JA, Klepser DG, Dobesh PP, Dering-Anderson AM. The Impact of Eliminating Backward Navigation on Computerized Examination Scores and Completion Time. Am J Pharm Educ. Dec 2020;84(12):ajpe8034. doi:10.5688/ajpe8034
2. Kimpo RR, Puder B. A neuroanatomy lab practical exam format in alignment with the universal design for learning framework. Anat Sci Educ. Nov-Dec 2023;16(6):1046-1057. doi:10.1002/ase.2316
3. Giruzzi NR, McKeirnan KC, Buchman CR, Bertsch T, Miller Z, Remsberg CM. A Mixed-Methods Exploration of the Effect of Disabling Backward Navigation on Calculations-Focused Computerized Examinations. Am J Pharm Educ. Nov 2022;86(9):ajpe8842. doi:10.5688/ajpe8842
4. Caetano ML, Pawasauskas J. A retrospective analysis of the impact of disabling item review on item performance on computerized fixed-item tests in a doctor of pharmacy program. Currents in Pharmacy Teaching and Learning. 2020/05/01/ 2020;12(5):539-543. doi:https://doi.org/10.1016/j.cptl.2020.01.018

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Author Bio(s):

 

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Pulses is a scholarly blog supported by a team of pharmacy education scholars.