Nurse Education Today 133 (2024) 106052

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Nurse Education Today

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Review

Changing test answers: A scoping review

Jean S. Coffey a, *, Annette T. Maruca a, E. Carol Polifroni b, Marianne Snyder c
a
231 Glenbrook Road, Storrs, CT 06268, United States of America
b
UConn Office of Clinical Placement Coordination, 231 Glenbrook Road, Storrs, CT 06268, United States of America
c
University of Connecticut, 231 Glenbrook Road, Storrs, CT 06268, United States of America

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: Various disciplines at all education levels worldwide are steeped in contradictions regarding the value
Backtracking of answer changing on exams. Therefore, the purpose of this scoping review was to explore the current evidence
Changing answers related to answer changing at the graduate and undergraduate level with a focus on nursing education.
Test wiseness
Design: The scoping review was guided by Arksey and O'Malley's scoping review framework. The team used the
Scoping review
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline to
report the findings.
Data sources: Using identified keywords such as answer changing, backtracking and test wiseness, researchers
located forty-nine relevant studies from multiple databases. After applying the predetermined inclusion criteria
including college students from all disciplines at the undergraduate or graduate level, ten remained for review.
Review method: The a priori protocol was; changing answers on tests will lower scores. Studies were randomly
assigned to each researcher for a first and second review using an author designed abstraction tool. Verbal
reconciliation was the third and final review of each article.
Results: The scoping review revealed that answer changes produced more wrong to right answers. In addition,
total score improvements with answer changes were as high as 45.15 %.
Conclusion: The synthesis of findings from 10 articles refuted assumptions that answer changing would negatively
impact the number of correct responses and potentially lower the overall exam score. The findings from this
scoping review support permitting answer changes. However, the varied research approaches in the studies
reviewed also suggest the need to conduct further research on the topic.

1. Background
When a group of nursing faculty were approached by nursing stu­
dents seeking guidance about the practice of changing answers during
an exam, the faculty searched the literature to inform an evidenced
based response. A comprehensive literature review revealed a dearth of
current studies on the topic, many written in the previous several de­
cades and very few were focused on nursing (Blakeman and Laskowski,
2020).
What became evident in exploring the scant available literature and
discussing the topic at a faculty meeting was that faculty adhered to how
they were taught, “go with your first answer and do not change it”. Some
faculty and students, however, were found to endorse changing answers
(Blakeman and Laskowski, 2020; Bultas et al., 2021; Merry et al., 2021;
Yonemoto et al., 2023). Despite the substantial body of evidence in
disciplines other than nursing to the contrary, it appeared many edu­
cators still held tight to the belief without evidence that students should
go with their “first hunch” (Ouyang et al., 2019).
These findings prompted the question of whether changing answers
to test questions is beneficial or detrimental to a student's test grade.
This topic has been debated for the past several decades in education
literature (Merry et al., 2021) albeit not recently. Waddell and Blan­
kenship (1994) noted that “more than 50% of faculty and students”
believed that changing answers would lower test scores (p. 155). Of
significance, when study variables such as gender, personality traits,
academic ability, item difficulty, and item position were correlated with
answer changing the only statistically significant variable was total test
that correlated positively with answer changing and test score (p. 157).
Still the belief and practice that changing answers would be detrimental
for student test scores persists (Nieswiadomy et al., 2001). Advice given

* Corresponding author.
E-mail addresses: jean.coffey@uconn.edu (J.S. Coffey), annette.maruca@uconn.edu (A.T. Maruca), carol.polifroni@uconn.edu (E.C. Polifroni), marianne.snyder@
uconn.edu (M. Snyder).

https://doi.org/10.1016/j.nedt.2023.106052
Received 6 June 2023; Received in revised form 13 November 2023; Accepted 18 November 2023
Available online 23 November 2023
0260-6917/© 2023 Published by Elsevier Ltd.
J.S. Coffey et al.
by educators on test-taking strategies surrounding changing answers
varies and may not be informed by best practices (Merry et al., 2021).
Answer changing as a test strategy is frequently misunderstood by both
test takers and educators. In addition to the variables mentioned pre­
viously, other variables such as how confident are the examinees in
changing answers, what reasons do they identify as to why they changed
an answer were examined by some for the interrelationship between
monitoring and control, or more specifically metacognition, and the role
this has during test taking (Bultas et al., 2020; Stylianou-Georgiou and
Papanastasiou, 2017; Papanastasiou and Stylianou-Georgiou, 2022).
Both the question and the answer to the question of the impact of
answer changing is not simple, which reinforces and prolongs the varied
practices among educators and students. This is further impacted when
considering the diversity of nursing students across the globe. “Evolving
cultural, economic, political, social, and technological forces in the
world community affect local and global nursing … .” (Kulbok et al.,
2012, p.1). For example, the health workforce in the U.S. is slightly more
diverse than the overall population (Snyder et al., 2018). Acknowl­
edging the multiple forces impacting nursing globally and the increase
in diversity in nursing, it is important to gain an understanding of the
best guidance to provide students on test taking strategies and answer
changing. With the combination of both paper and pencil tests and
increased move to computerized examination platforms, the choice to
allow test answer changing requires a thoughtful decision by faculty to
endorse backtracking and changing test answers (Bultas et al., 2020).
The impact of the evolution to computerized testing for nursing has been
described in Canada (Hobbins and Bradley, 2013), Ghana (Christmals
and Gross, 2019) and the US (Gloekler and Lucas, 2021) including the
school of nursing at the authors' university. The switch to a computer­
ized platform for administering examinations, moving away from paper
and pencil format, provides one question at a time. If backtracking is
offered as an option for students, the student would flag a question(s), go
forward or backward, and change answers during the examination.
With more computerized testing being used, it became clear the
decision to allow backtracking with answer changing was based on the
individual faculty member's belief on the benefit or harm to the student
with allowing backtracking and as a result backtracking was inconsis­
tently used by faculty across the curriculum. In some courses back­
tracking was permitted by faculty while in others, the test settings were
chosen to prevent backtracking. Despite existing literature that suggests
it is beneficial for students to change answers on multiple choice tests
(Bultas et al., 2021; Gaskins et al., 1996; Merry et al., 2021; Waddell &
Blankenship, 2004), the long-held belief by faculty and nursing students
continued that it is better to stay with the first choice or “first impres­
sion” and not to change the test answer (Nieswiadomy et al., 2001, p.
142). The attitudes and behaviors regarding answer changing are stee­
ped in contradictions worldwide, across disciplines, and at all levels of
education. Nursing is no exception to the conundrum regarding back­
tracking on exams and answer changing. Consequently, more informa­
tion is needed on this topic based on the scant available evidence.
The aim of this scoping review is to explore the available body of
evidence on changing test answers and provide an overview on this
topic. Changing answers were identified as: wrong to wrong (W–W),
wrong to right (W-R), right to right (R-R), and right to wrong (R-W). A
priori assumption is that changing test answers will lower student's
scores therefore, backtracking is not beneficial. This scoping review may
help inform colleges or schools of nursing protocols and have potential
to guide future studies.
2. Method
There are numerous formats to consider when conducting and
writing a systematic review. Randles and Finnegan (2023) compare the
varied methodologies to consider in a comprehensive review. Munn
et al. (2018) identified six reasons to consider a scoping review: identify
the types of extant evidence, clarification of definitions and/or concepts,
2
Nurse Education Today 133 (2024) 106052
examination of methods used in a specific field, characteristics of con­
cepts, precursor to a systematic review, and analysis of gaps in the
literature. Thus, we believe a scoping review was the method of choice
for this study as the body of evidence surrounding changing answers had
not been discussed nor used when faculty made decisions about test
taking strategies. A scoping review would aid us in knowing the evi­
dence and be a precursor to a systematic review if appropriate. There is
little in the nursing literature discussing whether answers should be
changed or not. Thus, a scoping review within the discipline of nursing
was needed. It is important to know and map the available evidence on
changing answers and it is also important to note that a limitation of the
scoping review approach is the quality of the evidence is not addressed.
We chose to address this limitation by including only research studies
which were published; in other words, we did not use reports or case
studies.
Arksey and O'Malley's (2005) scoping review framework guided this
study. Their steps include defining the research question, searching the
databases for relevant material, carefully selecting the studies using
predetermined inclusion criteria, recording the abstracted data, sum­
marizing the information, and sharing the findings with stakeholders for
validation and to inform them of the findings. The use of this framework
is described in the subsequent sections.
Beginning with the challenge from students as to why they could not
backtrack on exams, we asked the question “what does the evidence say
about changing answers?” With the assistance of the nursing liaison
from the university's library, Author # 1, using the keywords back­
tracking, changing answers, and testwiseness identified relevant studies
from CINAHL, Pub Med, Psych Info and ERIC prior to the actual start of
the scoping review process.
On examination of the initial search, it was noted that many of the
articles were dated in the 1990s, focused on changing answers on paper
tests, and included high school and elementary school students. Thus,
for this 2023 scoping review, the team decided on the inclusion criteria
of 1) articles written in English, 2) original research studies (meta-
analysis excluded), 3) peer reviewed publications, 4) no discipline to be
excluded, 5) addressed college, graduate, or post graduate students, and
6) the article published after 2000.
3. Study selection and abstraction tool
Author # 3 had previously conducted scoping reviews and led the
team in creating the abstraction tool. Data elements deemed important
were the inclusion criteria, as well as the geographic location of the
study, type of study design, medium of the test (computer or paper),
number of participants, discipline of participants, phase of education
(college, graduate, or lifelong learning), examination of right to right,
right to wrong and wrong to wrong answer changes, and overall sources
of evidence (abstraction tool available upon request). Every article was
reviewed independently by two members of the team and then recon­
ciled by the same team members together. If there was a disagreement,
the plan was to involve a third member of the team, but this was not
needed. The reconciled abstraction was used for this report.
The team used the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses extension for Scoping Reviews guideline to report
the findings (Tricco et al., 2018). This manuscript is the final stage of the
Arksey and O'Malley (2005) process wherein the results are shared with
stakeholder groups.
4. Summary of evidence
Ten articles remained at the end of the three-step reconciliation
process (see Fig. 1). Six out of 10 of the papers were from the USA. The
other four consisted of two from Germany, and two were multi-national.
The education level reported in the studies was primarily undergraduate
with a few graduate level exams. Demographic information on the
participants such as age or gender was not consistently provided across
J.S. Coffey et al. Nurse Education Today 133 (2024) 106052

Fig. 1. Process of article abstraction.

all studies. Students who participated as test takers were from a range of
disciplines including biology, education, physics, medicine, dentistry,
and nursing. The number of student participants across the ten studies
ranged from 36 in a study of Graduate Medical Examinations in Ger­
many (Fischer et al., 2005) to a high of 27,830 taking the USMLE-Step
Two Clinical Knowledge examination in the United States (Ouyang
et al., 2019). Table 1 provides additional details on the ten studies.
In the included studies, 9/10 exams, were described as high stakes.
The mode of exam delivery was primarily via computer (Fischer et al.,
2005; Liu et al., 2015; Ouyang et al., 2019; Pagni et al., 2017). The
remaining exams, excluding two studies that did not specify delivery
method, were paper and pencil. Stylianou-Georgiou and Papanastasiou
(2017) administered a paper test and asked the students to use a pen to
circle the answers. They felt this would clearly identify the initial answer

Table 1
Summary of articles used to inform the scoping review.
Author(s) Location Discipline Education Participants # tests Test High %W-R %R-W
phase formata stakes Wrong to right Right to wrong
testing

Bauer, Copp, & Fischer Germany Medicine College 79 1 NC Y 48.2 % W-R 21.6 % R-W
2007 30.2 % W-W
2.5 % grade
increase
Fischer, Herman, Kopp Germany Medicine GME 36 1 C Y 55 % 25 %
2005
George, Muller, & Bartz, USA Nursing College 135 472 exams P 55.6 % 27.5 %
2016
Liu, Ou Lydia, Global 12 Multiple Certification 17,638 2 Quantitative C Y NC NC
Bridgeman, Brent, Gu, Countries and verbal
Lixiong, Xu Jun, sections rGRE
Kong,& Nan
2015
Merry, Elenchin, & USA Biology College 79 2 NC Y 2.8 1.0
Surma
2021
Nieswiadomy, Arnold, USA Nursing College 122 7 P Y 86 % gained 6.7 % lost
&Garza
2001
Ouyang, Harik, Clasuer, USA Medicine Graduate 27,830 8 C Y 60 % 40 %
&Paniagua
2019
Pagni, Bak, Eisen, USA Dental Graduate 160 7 C Y 64.4 % Not Addressed
Murphy, Jennipher Students
Finkelman, & Kugel
2017
Stylianou-Georgiou and Europe Education College 120 1 P Y The average The average
Papanastasiou wrong-to-right changes from right-
2017 changes was 1.62 to-wrong was 1.26
(SD = 1.62). (SD = 1.5)
Wainscott USA Physics College 985 1 P Y More Less
2016
a
NC Not clear, P paper, C computer.

3
J.S. Coffey et al.
and any subsequent changes requiring crossing out a pen versus erasing
a pencil mark. However, some students chose, counter to the in­
structions, to make their original mark with pencil, erase and replace
their final choice in pen. The authors considered both pen and pencil
erased answer changes to determine their findings. This example high­
lights the variation in determining answer changes in the paper and
pencil tests.
The majority of the ten reviewed studies were nonrandomized with a
convenience sample of individuals required by their course of study to
take the exam/test at a prescribed time. Many of the results were from
the administration of one test in a discreet time period. However, in one
setting, Ouyang et al. (2019) examined results from two test blocks to
determine if the time of day impacted test results. They reported there
was no significant difference in results from answer changing between
the two blocks of time during which the tests were administered.
The results of answer changing on individual questions were re­
ported as Wrong to Right (W-R) or Right to Wrong (R-W). Consistently,
the percentages of correctly changing an answer from W-R when the
student chose to make a change was in the 48 %–60 % range in the
studies reviewed (Fischer et al., 2005; Bauer et al., 2007; George et al.,
2016; Ouyang et al., 2019; Pagni et al., 2017). The exception to this
range was in one of the nursing studies where the percentage from W-R
was 86 % (Nieswiadomy et al., 2001). Overall answer changes resulted
in a reduced change from R-W. This ranged from a low of 6.7 % in the
nursing study (Nieswiadomy et al., 2001) to the high of 40 % in the
graduate medical exam (Ouyang et al., 2019).
The change in the final exam scores was not always reported.
However, in those studies that did report, there was a gain in the total
score (Fischer et al., 2005; George et al., 2016; Ouyang et al., 2019;
Pagni et al., 2017). Total score increases with answer changes were as
high as 45.15 % in an exam administered to 27,830 medical students
using a battery of 8 test blocks (Ouyang et al., 2019). Answer changing
prompted an increased score of 14.59 points in an exam given to 160
dental students in the United States (Pagni et al., 2017).
The participants, test formats, and test delivery (computer vs paper
and pencil) varied across all the studies. In addition, the method of
determining a changed answer was unique in each paper reviewed.
Some of the authors also added information regarding the student or
faculty perspective on answer changing. George et al. (2016) published a
mixed methods study reviewing the answer-changing process and the
students' lived experience related to their anxiety impacting test taking
and answer changing. As far as the student perception of the value of
answer changing, in the studies where this was reported, there did seem
to be a positive correlation between the belief that answer changing was
beneficial and improved scores (Bauer et al., 2007). This belief may have
been impacted by faculty guidance regarding answer changing, as re­
ported in some studies reviewed (Bauer et al., 2007; Merry et al., 2021).
The impact of faculty guidance and student attitudes, while variables to
be considered, were not specifically addressed in most of the papers
included in this scoping review. However, Wainscott (2016) who was
initially convinced that answer changing was detrimental to student test
outcomes reported results consistent with the other studies reviewed.
After examining 985 exams taken by physics students, he stated the
positive results of answer changing were a surprise to him. This author
goes on to say how he has shared the information on answer changing
among his colleagues.
Out of the 10 studies reviewed, answer changing resulted in more
wrong to right answer changes than right to wrong. In the studies that
reported overall test scores, answer changing positively impacted those
scores. The results are derived from varying research approaches and
determinations for what constitutes an answer change. In addition, only
a few of the studies examined the impact of advice provided to students
about answer changing.
4
Nurse Education Today 133 (2024) 106052
5. Discussion
This scoping review explored the evidence of changing answers on
examinations. The synthesis of findings from 10 articles about changing
answers on objective exams refuted long held faculty and student as­
sumptions that changing answers would lower the overall exam score.
We have learned that although there was variability in testing across
these studies conducted in several multi-national locations as well as the
United States, allowing students the option to change their test answers
on an exam more often will result in changing from a W-R answer. In
fact, the studies in this review supported that changing answers would
result in a correct answer 48 %–60 % of the time (Fischer et al., 2005;
Bauer et al., 2007; George et al., 2016; Ouyang et al., 2019; Pagni et al.,
2017). Interestingly, among these studies, the only statistically signifi­
cant variable that positively associated with total test score was
changing answers.
Findings also supported that most examinees would change answers
on an exam if given the opportunity, so educators are encouraged to
allow backtracking on computerized exams whenever possible. Two
studies reported that faculty guidance in changing answers on an exam
(Bauer et al., 2007; Merry et al., 2021) may have been associated with
positive examinee experiences when deciding to change an answer on an
exam item. Faculty should encourage examinees before testing to
thoughtfully review questions they have answered but are doubtful of
their response before deciding to change their answers. Further
explaining that if the examinee decides to change their answers, it often
will lead to a correct response. Nursing programs and the faculty who
teach in them should consider the evidence that has existed for over 50
years and recommended by Morgan and Deese (1969) that changing
answers is consistent with the evidence and with careful thought will
more often result in a higher score and positively affect the final score.
Many nursing programs now administer tests using various laptop-based
testing programs within an existing learning management system or
through programs. Faculty administering laptop-based exams are
encouraged to enable exam settings to allow examinees to backtrack
while testing to review previously answered questions and encourage
them to review questions where they doubted their answer selection and
consider changing it.
As diversity increases and program populations include students
from various backgrounds and geographic locations, it is important to
examine exposure to multiple choice tests, education on test taking
strategies, and test taking metacognition (Papanastasiou and Stylianou-
Georgiou, 2022) for best outcomes. Evidence must be used for decisions,
which means more research is needed. This paper can be a precursor to a
potential systematic review and more research on the topic, specifically
in nursing.
6. Limitations
The literature is limited on this topic for nursing. The studies used for
the scoping review varied in method, exam process, and reporting of the
outcomes. While the primary indicators of answer changing from W-R,
R-W were reported in most of the studies, many other variables were
inconsistent, and research methods were wide ranging. In addition, the
participants, disciplines, and demographics were heterogenous, and the
majority w nonrandomized.
7. Implications for nursing education
The findings from this scoping review have implications for nursing
education globally to reconsider the misconception that changing an­
swers on a multiple-choice test will lower the students overall test score.
Students change answers, and as this review shows, this is done to
benefit the student. Review of nursing protocols should consider
allowing backtracking with the option to change answers as part of test
taking practice. With encouragement from faculty to reread the question
J.S. Coffey et al.
again and carefully reconsider the answers, the likelihood is greater that
students will go from the wrong to right answer. This can require faculty
members to change previously held beliefs regarding changing answers
and to be comfortable to support this approach. Future studies can
explore the impact of variables such as faculty guidance, student atti­
tudes towards changing answers, reasons given for changing or not
changing answers, and patterns of changing answers. The findings from
this scoping review support the need to conduct further research on the
efficacy of test taking strategies as well as faculty beliefs on such,
including targeted studies with nursing students worldwide.
Given that many universities now use exam software, the potential
decreased variation in evaluation of answer changes and clear grade
outcomes would enhance the findings of any future studies. Variables to
be considered in future studies could include clarity on exam format,
identification when the exam is high stakes, randomization with con­
trols, and any pre-test advice given to the students.
CRediT authorship contribution statement
Jean Coffey: Conceptualization, formal analysis, investigation, data
curation, writing, Annette Maruca: formal analysis, investigation, data
curation, writing Carol Polifroni: methodology, formal analysis,
investigation, data curation, writing Marianne Snyder: formal analysis,
investigation, data curation, writing
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
Thank you to Jillian Levesque, RN, Class of 2022 for her advocacy
regarding permitting backtracking and answer changing which promp­
ted this scoping review.
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