Perplexed by the NCLEX in Canada


To most Canadian nursing educators, the NCLEX is about as welcome in Canada as Donald Trump. I am not alone in being royally PO’d that the provincial nursing regulatory bodies decided to nix the Canadian Registered Nurses’ Exam (commonly known as the CRNE)to replace it with the NCLEX in 2015.

In case you’re not in nursing or you aren’t Canadian, the NCLEX is the American nursing licensing exam that all American nurses must pass after their nursing degree before they can register as a Registered Nurse.  It is an adaptive computerized test that will keep asking tailored questions until the program is 95% sure that the candidate is above or below the passing standard.  To be clear, I think that this format and system of testing is awesome.  What isn’t awesome is having to teach my students content that is American so that they can pass the test (as if we don’t already have enough content!).  The French translation of the NCLEX is also so bad that many Francophone students are failing because they can’t understand the questions (I’m talking outside of Quebec of course because they wisely decided to keep their own nursing exam). Moreover, although French NCLEX practice materials are starting to pop up (after they realized that it was an issue), there aren’t nearly as many resources for French students and educators as for their English-speaking counterparts.  Two giant strikes for the NCLEX.

I have no idea why on earth the provincial nursing regulatory bodies made this decision or if they understood the implications of their decision.  Initially I was told that it would be a Canadian version of the NCLEX and maybe they thought so too. It is not. It is the exact same database of questions for all candidates in all countries. I could be wrong but I think the rationale behind this is that the NCLEX supposedly is “context-free”. I attended an NCLEX workshop for nursing faculty two years ago and the facilitator explained to us how the test worked and how the questions are designed.  She also proudly stated that “the NCLEX has no context”.  What she meant was that the questions are designed to be applicable to all contexts. I would question that. Is nursing really that black and white?  Maybe some things are but I’d argue that real life requires professional judgement calls too.

There are also huge differences between the US and Canada in terms of how we view health care (as a service to be bought through insurance versus as a basic human right).  Specific examples of the “Americaness” of the exam include “the five rights of delegation” and the scope of practice for an RN versus and LPN (Licensed Practical Nurse)[or RPN (Registered Practical Nurse) in Ontario]. In Ontario where I started my nursing career, I worked on a hospital unit with half RNs and half RPNs. We both had our own patient assignments and although the RNs were able to be in charge and dealt with the more complex patients, we were never assigned an RPN to delegate work to and have them report back to us. They had autonomy and we all worked together as a team (for the most part). In the US, LPNs report directly to RNs and the RN assigns patients or patient care duties to them. LPNs are not allowed to engage in patient teaching or any of the nursing process (assessment, planning, evaluation, nursing judgment). (See the Joint Statement of the American Nurses Association and the National Council of State Boards of Nursing here). Why does this even matter? Well, now we have to teach our nursing students about delegation in their own province and the rest of Canada (it is not exactly the same from province to province) AND America. If we don’t tell them that delegation rules for the NCLEX they are going to answer those questions incorrectly and it sure as heck isn’t because we don’t teach them about delegation in Canada.

Some have argued that it is not an American test, to which I respond, then why are Canadian-specific NCLEX prep books popping up?  Is it because we are just another market that companies want to exploit, or is it because there is American content that Canadian students need to learn in order to do well on the test?

So where does this put us?  Precisely in a giant head-lock. We have excellent nursing programs across Canada and in general our nurses have more education and better quality education than nurses in the US. Many of their students still take 2-year associate degrees whereas in Canada all RNs have to have a four-year bachelor’s degree. Every day I am impressed with the quality of the education that the students get at UNB and especially with the amount of real life clinical they get (over 1400 hours).  However, now we need to add in NCLEX-specific content to make sure that our students are prepared to take an American nursing test. Not to prepare them for their practice as an RN – we do that exceptionally well already!

Clearly I have strong feelings about the NCLEX and not everyone will agree with me but I don’t think that Canadian nursing students should have to learn American content in order to become nurses in Canada. I also don’t think that nursing schools should be judged by their NCLEX pass rates. Passing the NCLEX or not doesn’t necessarily reflect the quality of a nursing program, but, rather the “NCLEX test readiness” of graduates. Some schools are starting to make it a requirement for nursing students to write the HESI NCLEX practice test and obtain a certain score before they can graduate and write the NCLEX. This ensures that pass rates on the actual NCLEX are high because it increases candidates’ test-taking skills and ensures that they don’t write until they are ready (sometimes after writing the HESI numerous times).  As a result, high NCLEX pass rates are not necessarily a reflection of the quality of the nursing school, but of the readiness of the student to write the NCLEX. I don’t think that it is a bad thing to take the HESI per se, but I do think it is misleading to compare first-time NCLEX pass rates between schools who have a HESI score requirement and those who do not. Taking these tests (the HESI and the NCLEX), attending NCLEX review sessions, and purchasing NCLEX study guides are also very expensive so making the decision to require the HESI is not one to take lightly.

So there you have it. The NCLEX has made it harder to become a nurse in Canada and more challenging to be a Canadian nursing educator. Arguably, it has also made it easier for Canadian nurses to practice in the US (if you don’t mind working in a f0r-profit health care system). I’m not a fan and I think that it was strange decision. It is also possible that I am not privy to confidential information about why this decision was made and, thus, do not fully understand the rationale behind it. That being said, until the situation changes, it really doesn’t matter if I agree or not, no matter how logical my arguments are; the fact is that we need to do what we can to prepare our students for an American test.




International New Graduate Nurse Research Colloquium

On June 20th, 2013, my supervisor, Dr. Heather Laschinger, hosted a wonderful research colloquium with invited researchers from around the world who all have a special interest in gaining a better understanding of the challenges facing new grads during their transition from student to professional nurse.

I feel so fortunate to have been invited!  It was a fantastic day of sharing ideas and research results, as well as thinking about what we can do moving forward to help nurses transition into their new roles.  I also had a chance to share a poster of my recent work about correlates of workplace mistreatment (i.e. incivility and bullying) directed towards new nurses in Ontario.   I wish that kind of research wasn’t needed to begin with but I think a lot of it has to do with structural factors of the work environment (e.g. leadership, workload, resources, support, etc. available to do your job) and personal factors that individuals bring with them to their job.  It is challenging to be kind and happy when you’re working overtime, have a heavy patient load, and are exhausted!    Nurses are valuable health human resources and we definitely have some work to do in supporting them/us and in particular, during transitions to new career roles (new grads or otherwise!).

Overall it was an inspiring day and I am so thankful that so many knowledgeable and fabulous guests were able to attend!    Christine also did a terrific job putting the event together and making the day run seamlessly 🙂  Nicely done everyone!

emily poster 2013