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Relative to the number of institutions assessed, Canadian nursing schools outperformed U.S. counterparts in the QS University Rankings.RICK WILKING/Reuters

A push to "harmonize" nursing education in Canada and the United States may threaten Canada's high standards in nurse training, according to a spokesperson for the Canadian Association of Schools of Nursing.

In a report released in March, Canadian nursing schools outperformed their U.S. counterparts in the QS World University Rankings published by Quacquarelli Symonds, a British company specializing in education and study abroad.

The University of Toronto's Lawrence S. Bloomberg Faculty of Nursing placed third in the world, after the University of Pennsylvania in first place, followed by Johns Hopkins University in Baltimore, Md. Relative to the number of institutions assessed on either side of the border, however, Canada had a greater proportion of nursing schools in the Top 50 list.

But Canada could lose that edge if Canadian regulators go ahead with a plan to bridge the differences in standards between the two countries, said Cynthia Baker, executive director of the Canadian Association of Schools of Nursing.

"Canadian nursing education is highly respected internationally and we should not be changing that to fit the needs of the U.S.," Baker said.

News of the plan to harmonize nursing education came in an article published in the spring edition of an online quarterly journal called Leader to Leader. The plan is part of a broader strategy to increase mobility among nursing graduates, according to a statement in the journal from a Canada-U.S. working group called the Harmonizing Education Regulatory Standards in Nursing. "Nurses often practice across borders, either by physical movement, distance education or telehealth," said the article, which was taken offline Wednesday in response to criticism. "Global consistency with nursing education regulatory approval standards would be beneficial for promoting more seamless mobility."

But according to Baker, Canada's nursing graduates are already at a disadvantage because of this strategy. Two years ago, Canada adopted a mandatory test called the NCLEX, developed in the United States to license graduates to practice nursing. In Canada, nursing schools in most provinces and territories were ill-prepared for the American test, which includes questions about care management that do not apply here, Baker said. In 2015, the pass rate for Canadians writing the test for the first time was 71 per cent. Among first-time francophone writers, the pass rate was only 27 per cent, "because the [French] translation was such a disaster," she said.

Canadian regulators adopted the U.S. licensing test without consulting non-regulatory nursing organizations in Canada. Canadian members of the harmonization team were drawn solely from provincial regulatory bodies, who are working with American partners without the knowledge of Canadian nursing educators or other professional nursing groups in Canada, Baker said.

Currently, Canadians (other than Quebeckers) must earn a bachelor of science in nursing to practice nursing in Canada, while Americans can practice with a BSN or an associate's degree in nursing or other diploma.

Baker cited research evidence showing that a baccalaureate-prepared nursing work force provides significantly better and safer health care. "We believe this harmonization plan would have serious negative implications for health human resources and for the Canadian health-care system," Baker wrote in a letter to Canadian and American regulators on Friday. Leader to Leader subsequently removed the article.

Canada's success in the QS World University Rankings for nursing is based on global surveys of academic reputation, perceptions of graduate employers, research citations and measures of the global impact of scholarly publications. The 2015 rankings were the first to include nursing as a subject.

At the University of Toronto, researchers at the Lawrence S. Bloomberg Faculty of Nursing include internationally recognized leaders in postnatal depression and maternal mental health, patient decision-making in response to genetic testing for breast cancer, and monitoring of equity and access to health-care systems.

"The research underpins the evidence-based-practice approach to helping students learn how to deliver care," said Linda Johnston, dean of the Lawrence S. Bloomberg Faculty of Nursing. In addition, students develop clinical expertise during placements at world-leading care facilities such as Sick Kids and Mount Sinai Hospital, said Johnston, who was previously employed at the University of Melbourne and Queen's University in Belfast.

Since research findings may not be appropriate for every patient, becoming a first-rate nurse requires a sound understanding of how to interpret the evidence in daily practice while considering the patient and family's decisions, Johnston said. "I've only been at the U of T for two years, but I am always astounded by the insights and critical thinking that our students display."

Like Baker, Johnston expressed concern over the Canada-U.S. harmonization plan. "It may not make sense," she said, noting that the United States has "a completely different model of care delivery."

An American-style system that licenses nurses to practice without requiring a university degree may not foster the academic career pathways that have made Canada a world leader in nursing education, Johnston said. "Academics are getting older," she pointed out. "Where is the succession planning?"

She added that preparing Canadian nursing students to operate in a U.S. environment may encourage them to move to the States for better career prospects. "That could lead to a nursing shortage [in Canada]," she said.