Graduate Perceptions of Factors Influencing Outcomes of National Licensing Examination in Nepal: A Mixed-Methods Study

Abstract

In the Nepali context, pass rates in National Licensing Examinations (NLEs) of Nepal Health Professional Council (NHPC) were low (NHPC, 2025). Many studies show that despite strong academic performance, unexpected NLE outcomes may arise due to the complex interaction of individual, institutional, and environmental factors (Graybow, 2015; Spohn et al., 2021; Tsunekawa et al., 2020; Webster, 2020). Such studies were not found in the Nepali context. So, the study aims to explore the trends and factors, graduates’ perceptions on trends and factors of NLE outcomes in the Nepali context by using a sequential explanatory mixed-methods study (Khadka et al., 2022; Molina-Azorin, 2016; Othman et al., 2020; Paudel et al., 2025). In the first quantitative phase, the NLE system database from the tenth to the fifteenth NLEs (n=8057) was analyzed and interpreted to explore the factors of NLE outcomes among graduates. In the second phase, an in-depth interview was conducted with 10 purposively selected graduates using the interview guideline developed with reference to findings and gaps from the first quantitative study. The first quantitative study revealed 3,233 (40.1%) attempts resulted in success and 4,824 attempts (59.1%) resulted in failure. A w-shaped trend line was observed, indicating a non-linear, fluctuating trend characterized by alternating declines and increases in success rate over the observed time period. Pearson chi Square test confirms the statistically significant association between NLE outcomes with age, gender, marital status, ethnicity, province of residence, course completion time, and number of NLE attempts. The second phase of a sequential explanatory mixed methods study, the qualitative study, confirms the findings of the first quantitative study. The association of self-efficacy beliefs and NLE outcomes was observed as explained by Bandura’s social cognitive theory in the study context. Based on the findings of the study, recommendations at the graduate and institutional levels were offered for optimization of NLE success among graduates.