Voices Raised: The NCLEX-RN Experience in Canada
The journey to this issue on the National Council Licensure Examination (NCLEX) began when the CJNL editorial director received two unsolicited NCLEX-focused manuscripts for consideration to publish. Adding to the growing body of articles and news stories published about the NCLEX since its 2015 implementation in Canada, the two papers revealed that the NCLEX-RN remains a controversial and unresolved issue for our profession. CJNL has long published special issues to focus attention on specific topics. Such focused publication creates a convenient repository of knowledge and information about a given subject, facilitating deeper exploration of the issue and serving as a historical reference point for the topic going forward. This issue continues that tradition by presenting 10 papers that discuss the NCLEX from the perspectives of researchers, policy makers, educators, students and a coalition of nurses that is vigorously advocating for remedies to address the disproportionately adverse impact of the NCLEX on students and especially on francophone writers. As CJNL's editor for policy and innovation, I was asked to serve as guest editor for this issue, and it has been my privilege to do so.
A registered nurse for more than four decades, I have an abiding interest in the structure, power and politics of our profession, including the principle of self-regulation granted to nursing and other health professions through legislation and regulation in Canada. By way of self-disclosure, I was the Canadian Nurses Association's (CNA) president-elect from 2010 to 2012, during which time the Canadian Council of Registered Nurse Regulators (CCRNR) was formed and subsequently (in 2011) announced the change to the NCLEX from the Canadian Registered Nurse Examination, which had been owned and administered by CNA as the entry-to-practice examination for the profession. It is important to note that in the course of preparing this issue, outreach was made to CCRNR by CJNL's editor-in-chief (Dr. Lynn Nagle) on two occasions: first as the issue was being planned and again when the last of the 10 papers had been received. On both occasions, CCRNR was invited to contribute its perspectives. A response was received to the second communication stating that CCRNR was unable to contribute but appreciated the offer. The e-mail also asked if the articles could be shared prior to publication. As it is not customary to share articles in press, the request was declined.
Objectives for the Issue
I am indebted to the authors of the papers presented in this issue for their time and effort in documenting their experiences related to the NCLEX. Individually, they have comprehensively and eloquently detailed their unique perspectives and experiences. Collectively, their submissions illuminate the NCLEX as a defining problem for the profession in Canada. The issue is organized into four sections – context, research, the francophone experience and perspectives from the Canadian Association of Schools of Nursing (CASN) and the Canadian Nursing Students Association (CNSA). A brief recap of the papers in each section is offered below to demonstrate the scope of the content in this issue.
The context for the NCLEX issue is ably provided by the authors of the first three papers. Kathleen MacMillan (2019) leads off the issue by inviting us to challenge our historical acceptance of the requirement for an entry-to-practice exam. She suggests that the concepts of "path dependency" and "mental models" may be limiting our thinking about other options for assessing the competency of graduate nurses for initial licensure. MacMillan's brief recap of the history of nursing education and the introduction of entry-to-practice examinations perfectly frames examination of the NCLEX through the collection of papers that follows. Her commentary notes that, to date, nursing is the only health profession in Canada to implement an international entry-to-practice examination, raising concern about the alignment between the exam and the culture and context of the country and the health system in which the nurse will practice. The paper does note that Quebec does not use the NCLEX-RN, a decision that reflects their local needs. It is also relevant to note that US exams have been used in Canada for Acute Care Specialty Nurse Practitioners (ACNPs) for reasons including a low number of specialty NPs in Canada and the similarity in practice.
The theme of misalignment between the NCLEX and Canadian culture and nursing practice is also addressed in other papers in this issue. In writing for the CNA, Villeneuve, Betker and Guest (2019) situate their discussion of the NCLEX in the imperative for the profession to retain the respect and trust of the public. The paper recounts historical milestones for the profession, including the establishment of nursing registration and entry-to-practice testing. Although CNA's advocacy related to the NCLEX was hampered due to perceptions of conflict of interest (CNA owned the previous entry to practice exam, which provided a revenue source), CNA has remained aware of the ongoing concerns about the NCLEX, and the paper calls for mechanisms to be implemented that inspire confidence in the ability of nurses to deliver safe, high-quality care. Dr. Kirsten Woodend (2019) experienced the introduction of the NCLEX as an educator and dean of nursing at Trent University as well as in her then-role as president-elect for CASN. Woodend's recollections of NCLEX implementation touch on the nature of the process used by regulators to implement the NCLEX as well as economic considerations and joins others in voicing concern about implementing a US examination not reflective of the Canadian culture or context. Woodend challenges the view that passing an entry-to-practice exam ensures patient safety, pointing to the absence of supporting evidence. Sadly, despite CASN's record of comprehensive, strong and sustained leadership on the NCLEX issue, Woodend writes that she finished her term as president feeling that she had failed in addressing the persistent concerns about the NCLEX and today remains apprehensive about the impact of the NCLEX on the Canadian nursing curriculum and francophone nurses.
McCloskey et al. (2019) conducted a retrospective study of predictors of success for anglophone NCLEX writers at one Canadian university. Factors that created apprehension by educators and students related to the introduction of the NCLEX-RN are described, and the adverse impact on graduates and educators related to failing the exam is discussed. For the cohort studied, the study findings indicated that academic performance was a good predictor of success with the NCLEX-RN. Campbell et al. (2019) report on their study of the introduction of the NCLEX-RN to Canada. Beginning by noting countries that require a registration examination and those that do not, the authors then compare healthcare and nursing education in Canada and the United States, discuss cost implications for students and faculties in the context of an exam that is part of a multi-billion dollar industry and raise questions about the test validity of the NCLEX-RN.
A commentary by authors May and Singh-Carlson (2019) rounds out this section and brings many of the issues associated with the NCLEX into sharp focus. Nursing professors, who have taught in both Canada and the US, report on the findings of conversations they held with 29 Canadian nursing deans, directors and organizational leaders about the NCLEX, augmented by their review of media coverage, publications and communications materials. Their comprehensive discussion is framed by two key questions: does adoption of the NCLEX situate the US regulatory and education models as the "international gold standard," and did Canadian regulators adequately involve key nursing leaders and stakeholders in deciding to use the NCLEX? They conclude that the NCLEX-RN examination was "designed to operate in a healthcare system that should not, by any reasonable argument, be replicated elsewhere" (p. 57) and that Canadian regulators failed to meaningfully involve key nursing leaders and stakeholders in the decision to implement NCLEX.
Two of the papers in the issue focus exclusively on the impact of the NCLEX for francophone nursing graduates. Lalonde's (2019) paper is powerfully framed by the title: "The Forgotten: The Challenges Faced by Francophone Nursing Candidates Following the Introduction of the NCLEX-RN© in Canada." The author observes that no information on the translation of the English NCLEX to French was provided during the introduction of the NCLEX, and there was no consultation with francophone nursing educators about the new exam. The paper reports the persistently lower pass rates for French versus English and highlights the dramatic decrease in the number of francophone writers across Canada. Referencing media interest and early studies on the NCLEX-RN implementation, Lalonde identifies the absence of preparatory materials in French and the poor quality of the translation as key contributors to the poor pass rates. Framed by the author's piercing questions, the lack of preparatory resources is examined, including the claim by regulators that providing them would be a conflict of interest. In the context of Canada's status as a bilingual country and the Canadian Official Languages Act, the imperative for the availability of a sufficient number of nurses to provide safe and competent patient care in the French language is explained. The paper's eloquent conclusion is a compelling call to action: "Should this trend continue, we will soon not have any French writers to worry about."
Guerrette-Daigle et al. (2019) document the advocacy being carried out by a group of concerned nurses in New Brunswick to address the adverse impact of the NCLEX-RN in that province. The authors recall that they left a 2012 informational meeting provided by CCRNR and the National Council of State Boards of Nursing (NCSBN) with few answers to their questions about how the linguistic rights of francophones would be accommodated. Recognizing the inequity in resources available for anglophone versus francophone students, the University of Moncton (UdeM) moved quickly to support their francophone students. However, a precipitous drop in pass rates for francophone students was experienced in the first year of the NCLEX – from 91% in 2014 (previous exam) to 26% in 2015 (NCLEX) – and lower pass rates have persisted. The Nursing Association of New Brunswick (NANB) received a "groundswell of criticism" about the exam, and a complaint was made to the commissioner of official languages in New Brunswick, which resulted in NANB being found in violation of a subsection of the Official Languages Act. Nonetheless, no resolution has yet been achieved, and there is new urgency as contract renewal with the NCSBN comes up for NANB and the other nursing regulators in Canada. Pass rates for UdeM graduates are still below the national average, and the authors list the consequences, including shattered dreams, broken career paths and a deepening nursing shortage in the province. Referencing the recently released Canadian Examination for Baccalaureate Nursing (CEBN) by CASN as a possible replacement for the NCLEX, the authors conclude that "while it will require courageous leadership to correct the current regulatory quagmire, it can be done [and] must be done."
Writing for CASN, Executive Director Cynthia Baker (2019) reports on the development of a new examination, the CEBN. The CEBN is a psychometrically sound examination relevant to the Canadian healthcare and practice context. Informing the need for the new exam was the finding that 65% of the entry-to-practice competencies required by Canadian nursing regulators are not addressed or are only partially addressed in the NCLEX. Of the four committees comprising the governance structure for the development of the CEBN, two were co-chaired by francophones, and all materials are provided in English and French. In response to a 2017 inquiry from NANB, CASN will make the exam available to any regulatory body wishing to use it as a registration exam. The exam will be ready for release in 2020, and it is reported that some schools will make taking the exam a requirement for their graduates. Although the paper notes that some regulatory bodies have indicated an interest in the exam for registration in their jurisdiction, none have yet done so.
The last word in this issue is given to nursing students through author Rebecca John (2019), who writes for CNSA. John documents the advocacy undertaken by CNSA to publicize the adverse impact on so many students related to implementation of the NCLEX. The diversity and depth of CNSA's actions to address NCLEX issues are staggering, including multiple press releases, successive position statements, letter-writing campaigns, social media blitzes inclusive of Facebook Live Q & A sessions and creation of an online repository of NCLEX writing resources for graduates. John's disappointment is evident as she recounts the lack of response from regulators to CNSA's persistent efforts to communicate their concerns. CNSA has more recently focused on the profound disadvantages of the NCLEX for francophone students, and John ends her paper by calling for solutions that ensure "culturally competent care that strongly represents the nature and values of the Canadian healthcare system."
Reflections on the Assembled Papers
The problems arising from NCLEX implementation in Canada documented in these papers reveal power as a central issue. For example, many references are made to the failure of regulators to consult with key stakeholders in the selection of the exam (particularly with the educators who are responsible for educating the students), to listen to the issues experienced with implementation of the new exam or to take meaningful action to remedy those issues. The power to determine and implement policy that has far-reaching implications for health human resources and public safety is out of balance. In the NCLEX-RN situation, we see the intersection of power held by regulators, regulatory boards/councils, the NCSBN in the US and capitalization of the NCLEX-RN, (i.e. selling the NCLEX and thus realizing revenue) including its access to an international market, versus the Canadian nursing profession weakened by the reduction in power of professional associations, educators, new graduates, students and linguistic and cultural minorities.
The right of self-regulation is given to our profession at large, yet its powers are currently enacted by a single group of nurses (regulators) who have acted unilaterally with regard to the NCLEX and have tended to dismiss or ignore entreaties by individual nurses and nursing stakeholders. Finding a way to balance this power in the public interest is both a challenge and an opportunity, requiring joint effort by the profession and the government. The NCLEX-RN experience in Canada presents an opportunity for the profession to strengthen self-regulation in the public interest. Seizing that opportunity could encompass critically examining aspects of nursing regulation in Canada including governance structures and processes such as term limits for CEOs, mandatory board development/education for councillors/board directors by third parties that emphasizes that the CEO and staff work for the board and the public and not vice versa, routine use of mechanisms to avoid and/or challenge groupthink in decision making and ensuring that content highlighting the roles of councillors/directors is included in nursing curricula. Undertaking a comprehensive analysis of the economic impact of the NCLEX is another initiative that emerges from the articles in this issue. The unanticipated cost to students for purchasing preparatory materials and paying exam fees, added costs to nursing faculties, the loss of income associated with failing the NCLEX and the cost to purchase the NCLEX from NCSBN are just some of the inputs into economic analysis. Given that more than one of the papers calls for consideration to eliminate the need for an entry-to-practice examination, imagine if all of those costs were instead invested in strengthening nursing education and practice supports for new graduates!
As noted in one of the papers, we are at the five-year mark of NCLEX implementation (2015–2020). This juncture offers an excellent opportunity for regulators to initiate focused efforts to work with key stakeholders about the future of the NCLEX for two reasons: first, NCSBN's construction of "the Next Generation NCLEX," an initiative that ironically seems to validate claims that the NCLEX does not test the right things (Flores-Harris 2019), and second, the pending availability of CASN's CEBN. These papers make a compelling case for active and meaningful consultation and collaboration.
There is already evidence that governments are paying new attention to self-regulation, as illustrated by the Inquiry into the Performance of the College of Dental Surgeons of British Columbia and the Health Professions Act (Cayton 2018), commissioned by BC's health minister. In his report, Cayton declares that "the Health Professions Act is no longer adequate for modern regulation," observes that "professional regulation … may create a cartel or monopoly" and states that "patients he spoke to do not have great confidence in colleges or health regulators generally" (p. 72). All of these findings reflect the criticisms of self-regulation reflected in the NCLEX-RN experience so thoroughly documented in this issue. We do not want to lose the privilege of self-regulation for the nursing profession in our country. To preserve the principle of self-regulation and address the issues associated with the NCLEX revealed by the papers in this issue, we must establish new mechanisms for collaboration and consultation between regulators and nursing stakeholders, find and implement solutions for the inequitable impact of the NCLEX for francophone writers, re-examine entry to practice assessment and initiate a robust and inclusive national discussion on self-regulation. Taking action in these ways will ensure that these papers have not been written in vain.
Barbara Mildon RN, PhD, CHE
About the Author
Barbara Mildon RN, PhD, CHE, Courtice, ON
Baker, C. 2020. Promoting Quality in Nursing Education in Canada through a Canadian Examination for Baccalaureate Nurses. Nursing Leadership 32(4): 81–91. doi:10.12927/cjnl.2020.26098.
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Cayton, H. December, 2018. An Inquiry into the Performance of the College of Dental Surgeons of British Columbia and the Health Professions Act. Retrieved December 31, 2019. <https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/professional-regulation/cayton-report-college-of-dental-surgeons-2018.pdf>.
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Villeneuve M.J., C. Betker and T. Guest. 2020. The Canadian Nurses Association: Reflections on the NCLEX-RN through the Lens of Nursing History and Evolution. Nursing Leadership 32(4): 17–21 doi:10.12927/cjnl.2020.26105.
Woodend K. 2020. Transition to NCLEX-RN: Reflections from a CASN Past President. Nursing Leadership 32(4): 22–9. doi:10.12927/cjnl.2020.26104.
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