Is it our job to educate RNs for Canada or for the United States?
The following is a guest blog by Dr. Jennifer Medves, Vice-Dean (Health Sciences) and Director of the School of Nursing at Queen’s University.
In December 2011, the College of Nurses of Ontario (CNO), and the regulators across the country, announced that as of January 1, 2015, graduates of nursing programs would no longer be required to pass the Canadian Registered Nurses Exam.[i]
The same press release stated that the National Council of State Boards of Nursing had been selected “… to partner in the development of a state-of-the-art, computer-adaptive RN entry exam.” The statement went on to clarify that in order “… to ensure the exam meets Canadian requirements, the ten regulators will participate in oversight of the exam development and administration.” The wording of the press release, including words such as “partner” and “exam development and administration,” suggested to educators that this would be a new, Canadian-based nursing exam that would be housed on the National Council of State Boards of Nursing computer system.
Instead, we later discovered that our nursing students would be required to pass the NCLEX-RN – an American nursing exam. What followed was an overwhelming sense that we had lost a huge battle without even knowing one was occurring. While there was much rhetoric about the exam, we were subsequently assured that nursing practice is the same on both sides of the border, that all questions on the exam with American-only content would be excluded for Canadian students, and that the decision was final and irrevocable. That said, our concerns remained and we began to petition everyone we could to try and reverse the decision while simultaneously helping to prepare our students for the exam. Nursing faculty from across the country went to every available conference, seminar, and webinar to try and find out as much as possible about the NCLEX-RN.
At the same time, we were inundated with American advertising that assured us that we needed help from all types of for-profit organizations to ensure we met the requirement in our programs to achieve the pass rate of 88% for all our students. At Queen’s we were naturally horrified that an 88% pass rate was considered to be good! With the CRNE, our expectation has always been a 100% pass rate, and we become very concerned if we have more than one failure.
Overwhelmed by the ever-increasing amount of advertising that we were receiving, we partnered with the 13 other university nursing programs in Ontario and conducted a thorough assessment of all of the ‘help’ on offer. Through an RFP process, we selected two organizations to provide teaching material at a reduced rate to all universities. One of the criteria was that written material would be available in French, and both organizations selected assured us that material would be bilingual. To date, this requirement has been partially met and is very sparse.
We all worked diligently to include NCLEX-RN type questions into our assessment of nursing knowledge across the curriculum. We reassured our students that former Queen’s nursing graduates who were interested in working in the US had taken the test in the past and had fared well. We tried to avoid unduly alarming the students, but encouraged them to purchase new study guides and study really hard.
Unfortunately, when the exam was rolled out, our worst fears came true. The media began to report on some of the student experiences in taking the exam, some of who described it as “terrible,” “biased,” and “a crapshoot.”[ii] While many were embarrassed of the high failure rate and wondered about the damage to our reputation by going public, the College of Nurses of Ontario publishes the rates on their website for the whole world to read and the damage to the reputation of Canadian educated nurses is already done.
The Canadian Association of Schools of Nursing (CASN) carefully mapped the entry-to-practice competencies required of new nursing graduates in Canada against the NCLEX-RN specified test areas, and the results were frustrating. “One third of the competencies expected of a Canadian nurse are not addressed at all by the NCLEX-RN and over a quarter are only partially tested. This represents more than half of the competencies” explained Dr. Cynthia Baker, Executive Director of CASN and Professor Emerita of the Queen’s School of Nursing. “Examples of what is missing include nursing activities reflecting national guidelines related to patient safety, interprofessional collaboration, client-centred care, and cultural safety, each of which is an essential element of patient safety in the Canadian context. By the same token, many activities listed in the NCLEX-RN test plan aren’t among the required entry-to-practice competencies.”[iii]
The outcome of the exam roll-out has not only concerned the nursing community. Reza Moridi, the Minister of Training, Colleges and Universities agrees that Canadian nurses should be tested using a Canadian exam. “Our regulatory colleges, including the College of Nurses, should design a Canadian exam rather than borrowing something from other countries,” he told the Toronto Sun. He also dismissed the high Canadian failure rate as a signal of our teaching standards. “Our colleges and universities are training first-class nurses. Our nursing graduates — their education, their work ethic — are among the best in the world.”[iv]
Moridi went on to say he has great confidence in Ontario nursing schools, which educate 4,500 students each year. “They have to design their own Canadian or Ontario exam which suits our requirements and follows the metric system instead of the imperial system, which is very different and could be very confusing,” Moridi said. “Also, the French translation should be perfect.” [v]
Health Minister Eric Hoskins says since this is the first year the test has been used, it’s important to get it right. “I think we all agree that the exam that a health-care practitioner should take in this province should reflect the curriculum that they’re taught and that it should be a useful tool to measure their preparedness for entering the workforce,” he told the Toronto Sun. [vi]
So where does this leave us in the profession of nursing? Disappointed, angered for the students, and feeling absolutely helpless.
Is it truly the long term plan for our Canadian health care professionals to be tested using American exams? Other than serving to improve portability, what does this really accomplish? We spend four years with our students, preparing them for the reality of Canadian health care, teaching patient safety, interprofessional collaboration, client-centred care, and cultural safety. Should we not bother? Are we now in the business of preparing our nurses for the US? I certainly hope not.
Please join me in supporting and advocating for our Canadian nursing graduates in the comments below.