Re: CJNL 32.4 - Special Focus on the NCLEX-RN Experience in Canada
Thank you for initiating an important conversation regarding NCLEX-RN implementation and experience in Canada. We are three nursing leaders in the province of British Columbia (BC) with continued interest in the governance, regulation and contribution of nursing locally, provincially and nationally. We hold or have held senior policy positions in BC, including in roles responsible for nursing regulation and practice. It is not our intent to replay the past in relation to the exam; rather, our commentary is intended to position the discourse in the broader context of practice regulation and the roles/responsibilities of regulators in our country.
In Canada, provincial and territorial governments have legislated the authority to regulate nurses to regulatory bodies, which includes ensuring that applicants for registration have the required knowledge, skills and abilities before they can practise nursing. However, the assumptions inherent in what traditionally was a self-regulating model are no longer relevant to today's health consumer and to the protection of the public. Over the past decade, the health needs of Canadians have changed, as have the expectations of Canadians from all healthcare providers. It is essential that a valid and reliable measure of competencies is in place. Canada is lagging in its own necessary regulatory reforms. Professional regulation has a public intention to ensure quality but may, in practice, create a monopoly.
It is within this evolving context, we would argue, that regulators have been considering the required framework for the future, including the entry-to-practice examination. Why consider changing that exam? A multiple-choice paper-and-pencil exam is neither the gold standard nor the minimum standard we would want to measure entry-level competencies and for the corresponding level of risk to the public. To select the best possible examination, the regulators issued a request for proposals from proponents, and the NCLEX-RN was chosen. While we agree with the suggestion that the examination should be a valid, reliable measure of the required competencies and skills for entry-to-nursing practice, we believe that our regulatory colleges have expressed their confidence that the computer-adaptive technology is the most valid and reliable measure of entry-to-practice competencies, and NCLEX-RN has demonstrated its accuracy at measuring such competencies in the public interest.
We do not suggest that the implementation of the NCLEX-RN was without flaws. Consultation and communication could have been improved. The focus on francophone students and preparatory materials for them was not managed well, and this issue needs to be addressed. But whether it would have substantively changed the outcome is unknown.
We are now five years into the use of the NCLEX-RN. Examination pass rates are appropriate. In 2018, the overall first-attempt pass rate was 82.9%. For Canadian-educated exam writers, the first-attempt pass rate was 85.6%, and for internationally educated nurses, it was 60.1%. By the end of 2018, the current pass rate for the 2017 cohort was 96.1% (Canadian Council of Registered Nurse Regulators, personal communication, February 2020). Our regulators are confident in the examination's ability to measure the competencies for safe, appropriate entry-to-nursing practice. Perhaps we should be as well. Their confidence is not only a result of the pass rate data but also because of the extent to which they oversee and manage the development of the exam and exam content for Canada. Work is advancing on more sophisticated models of measuring competencies and clinical judgment, and our Canadian regulators are involved in improving how regulation is effectively used to ensure safe nursing practice.
The genesis of this CJNL issue originated with the submission of two articles related to the implementation of and experience around the NCLEX-RN in Canada. We would suggest that this discourse needs to be modified, and we should be examining the pan-Canadian regulatory framework that should be developed and achieved for nursing. In addition, a thoughtful examination of entry-to-practice education for Canada should be undertaken. Building off the recommendations in Villeneuve and MacDonald's (2006) Toward 2020: Visions for Nursing and the National Expert Commission's (2012) A Nursing Call to Action, we would suggest that our collective efforts need to focus on establishing a pan-Canadian regulatory framework, integrating nursing education and supporting optimal scopes of practice. Despite calls for action from multiple authors and groups, we are failing to focus on the imperative before us.
As nurses, we are passionate about our profession and the structures, roles and decisions that impact it. Authors May and Singh-Carlson (2019) discussed their perspective on a failure of leadership at the intersection of regulation, education and practice. Our profession has a thoughtful direction recommended in these areas. Will we fail in our leadership again by focusing on the past instead of the future?
David Byres, DNP, RN, CHE
Natasha Prodan-Bhalla, DNP, MN/NP, BSN
R. Lynn Stevenson, PhD, RN, FCCHL, ICD-D
About the Author(s)
David Byres, DNP, RN, CHE, Vancouver, BC
Natasha Prodan-Bhalla, DNP, MN/NP, BSN, Vancouver, BC
R. Lynn Stevenson, PhD, RN, FCCHL, ICD-D, Victoria, BC
May, K. A. and S. Singh-Carlson. 2019. The Adoption of NCLEX-RN in Canada: A Failure of Leadership at the Intersection of Nursing Regulation, Education and Practice. Nursing Leadership 32(4): 57–65. doi:10.12927/cjnl.2020.26101.
National Expert Commission. 2012. A Nursing Call to Action: The Health of Our Nation, The Future of Our Health System. Canadian Nurses Association. Retrieved September 21, 2020. <https://www.cna-aiic.ca/~/media/cna/files/en/nec_report_e.pdf>.
Villeneuve, M. and J. MacDonald. 2006. Toward 2020: Visions for Nursing. Canadian Nurses Association. Retrieved September 21, 2020. <https://www.nln.on.ca/images/downloads/Toward-2020%20Vision%20for%20Nursing%20CNA.pdf>.
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