As the first year of Canada’s new entry-to-practice exam, the NCLEX-RN, draws to a close, preliminary results are disconcerting for nursing students, educators and regulators.
In 2011, the Canadian Council of Registered Nurse Regulators (CCRNR) announced that the National Council of State Boards of Nursing, Inc. (NCSBN), an American organization, would begin offering NCLEX as of Jan. 1, 2015. Canadian nursing graduates in every province and territory (except Quebec) need to pass the NCLEX as a requirement for registration and licensure.
“Canada’s RN nursing regulators made the decision to move to the NCLEX-RN using a RFP process,” CCRNR president Anne Coghlan says. “The NCLEX-RN met all of our requirements for an entry-to-practice exam. In addition, extensive research that compared Canadian and U.S. entry-level nursing practice found that practice was similar.”
NCLEX is a computer-adaptive test (CAT), which is an electronic system that adjusts to each test-taker’s ability as questions are answered. As exam writers answer questions, the system assesses them on how well or poorly the test-taker performed before generating the next question. No two exams will be the same. According to NCSBN’s website, CAT generates less “easy” items for high-ability candidates and less “difficult” items for low-ability candidates to avoid having candidates guess on items that are too difficult, which can skew results.
“The number of questions a person answers is determined by how long it takes for the CAT algorithm to confirm that the writer has responded consistently above the passing standard,” Coghlan explains. “The fewest number of questions it takes to determine this is 75; the maximum number of questions a writer will be asked is 265.”
During the three years between announcing the change and launching the exam, CCRNR and NCSBN worked with educators and provided access to several resources to give them the information they needed to prepare students for the exam, Coghlan says.
However, those who wrote the exam in the first half of this year feel differently about how the change was implemented. “We were told in second year that we would be writing the NCLEX and I honestly think some of the professors were as surprised as us,” Alberta graduate Christine Blacquière says.
“For the past four years, we were all taught a curriculum based on the [old exam] and at the last minute we were given a different test developed by a different country with different curricula,” says B.C. graduate Nikki Doherty. “When we pointed out glaring issues arising from practice exams, we were told that when it came to the loads of specialty content we were being asked and hadn’t been taught, we were outright told to give it our ‘best guess.’”
Doherty said prep material included information about U.S. government branches and health-care legislation and questions about private insurance, interpreting EKGs, biological warfare, cultural care related to larger American minority groups, pharmacology, and specialties, including maternity, pediatrics and oncology.
Coghlan disagrees with critics who call NCLEX an American-centric exam, saying Canadian and American regulators, educators and nurses worked together to develop the current exam. “The NCLEX is not an American exam, nor is it a Canadian exam: it is a nursing exam. It does not test the writer’s knowledge of a particular health-care system, history, or legislation. It tests whether an applicant to the nursing profession has the knowledge, skill, and judgment needed to provide safe care to the public.”
Less-than-hoped-for pass rates
On Sept. 1, Canada-wide and provincial/territorial breakdowns of the exam results for the first six months of the year were released. The national pass rate was 70.6 per cent — more than 10 percentage points below the Canadian pass rate in recent years and eight points below the American pass rate.
“The preliminary posted pass rates definitely do raise some concerns,” says Dawn Tisdale, president of the Canadian Nursing Students’ Association (CNSA).
“I think the questions every health-care policy-maker is asking today are ‘how did this happen?’ or ‘was it that this wasn’t thought through far enough?’” says Linda Silas, president of the Canadian Federation of Nurses Unions.
Putting the preliminary results into perspective is important this early out. “This data represents the first six months of the year and in some jurisdictions it represents a small number of writers,” Coghlan says. “With the launch of a new exam, it is common to see variance in the results as educators and students become familiar with the requirements and new testing structure and process.”
She adds that Canadian writers are passing the exam on their second attempt at a higher rate than American graduates, although hard data is not available yet.
Canadian Association of Schools of Nursing executive director Cynthia Baker urges action to improve the quality of the French exam. “It’s a Charter of Rights matter.”
With the highest francophone graduate population, New Brunswick also had the lowest pass rate at only 54.3 per cent. Among the 265 N.B. graduates who wrote the exam, only 144 passed; in comparison, among the 254 Nova Scotia graduates, 205 (80.7 per cent) passed.
Where the number of test-takers is low at the midway point of the year, the pass rate could easily change before the end of the year, Coghlan says. The number of English and French exams taken is unavailable until there is a full year of data.
Coghlan confirms that the regulators continue to work with a Canadian translation panel of fluently bilingual nurses and educators who review exam items for language equivalency on an ongoing basis. The NCLEX test plans and other resources exam writers may find useful have been translated. CCRNR is working with NCSBN to determine if any additional materials need to be translated.
Until the translation problem has been addressed, Tisdale says CNSA would like to see francophone students be allowed to write the exam more than the maximum three times.
Impact of the results
Mary Ellen Gurnham, executive director, Learning and Professional Practice, Central Zone, Nova Scotia Health Authority, says she sees the benefit of students being able to complete the exam more often during the year; however, she says she believes many graduates may be procrastinating taking it due to fear of the unknown format and allowing time for possible bugs to be worked out of the system.
“The impact [of the exam] will be felt across the system,” Silas worries. With 25 per cent of the nursing workforce ready for retirement, public safety could be put at risk if fewer graduates are getting through, or getting through slower.
“This [delay and confusion] is one of the system and human level costs,” Baker says. “We’re the only health profession in Canada that does not have a national exam. I don’t think it’s in Canadians’ best interests to outsource the licensing of a health professional to the licensing body of another country.”
Acknowledging that all change creates challenge and there is room for improvement, Coghlan says CCRNR and the regulators will continue to work with educators to determine why there is a wide variation in results. “There may be things to learn to improve performance in programs where the pass rates are below the national average.” CCRNR and the regulators “will continue to ensure that educators and students are aware of the resources available to them [and] Canadian nurses will continue to participate in exam development and review processes.”
And that is the key, the silver lining, if you will — regulators and educators are discussing the changes that need to be made. “Nursing regulators in each jurisdiction will plan to work with their stakeholders as needed,” Coghlan says. “As the national council, CCRNR will continue to ensure the jurisdictions have accurate information about both the exam and the data on exam writes.”
“Canadians, nursing students, governments and employers can be confident that the nursing profession is closely monitoring the situation and will work with all groups to resolve it,” CNA president Karima Velji says.
Gurnham does not see value in playing the “blame and shame game,” but welcomes the opportunity to work together in partnership. “We need to come together as a leadership and find solutions; we need to model professional cooperation just like we are telling our nurses at the bedside to do. Because we all want our new graduate nurses to be successful.”