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The NCLEX exam adapts to a test-taker’s ability, using an algorithm to choose the type and number of questions based on how the student is doing on the exam.Chad Mcdermott/the Globe and Mail

Nursing educators are raising concerns over a new national licensing exam, saying the percentage of students passing the test is lower than under a previous regime and that some students have encountered questions that reflect the American – not Canadian – health-care system.

The shift to the new exam was announced in 2012. As of January, graduates in every province and territory except for Quebec and Yukon have had to write the National Council Licensure Examination, or NCLEX, to be licensed in their home provinces.

Previously, nursing graduates took a paper-based exam, which was administered by the Canadian Nurses Association three times a year. NCLEX is a computer-adaptive test that can be taken throughout the year. The exam adapts to a test-taker's ability, using an algorithm to choose the type and number of questions based on how the student is doing on the exam.

The first round of exam results are now in – and they are a cause for worry, according to some.

The national pass rate, at 70.6 per cent, was more than 10 percentage points below the pass rate "for the last number of years" under the previous regime, the Canadian Association of Schools of Nursing said Wednesday in a statement.

The pass rate for Canadians was also lower than the 78.3-per-cent pass rate for Americans.

Those results confirmed the worries of Dianne Tapp, dean of the faculty of nursing at the University of Calgary. "There were questions on the exams ... that were not appropriate for Canadian nursing," she said.

Asked for specifics, Dr. Tapp said students told her they encountered questions that referred to Obamacare – the nickname for the health-care reform law in the U.S. – and the U.S. Food and Drug Administration.

Provincial regulatory groups and the Canadian Council of Registered Nurse Regulators, an umbrella group formed in 2011, have tried to counter concerns that NCLEX is "an American test."

In a question-and-answer document on its website, the council said those taking the exam would not be asked questions about the American health-care system or see other American content on the exam.

That contradicts feedback Dr. Tapp says she has received, including from one student who said she was asked to describe the side effects of a drug approved by the U.S. FDA.

A spokesperson for the Canadian Council of Registered Nurse Regulators did not immediately reply to a request for comment.

The new exam was supposed to be adapted to Canadian requirements, but instead Canadian schools are having to prepare their students to pass an American exam, Canadian Association of Schools of Nursing president Kirsten Woodend said in a statement, adding that "the tail is wagging the dog."

Others took a more nuanced view, acknowledging concerns about the test while saying any change involves an adjustment period.

"The questions may be worded a little bit differently, but the purpose of the exam is the same," said Maura MacPhee, associate director at the University of British Columbia's school of nursing.

"As educators, our mandate to the public is to produce students who are competent and safe at entry level of practice. So regardless of what the exam is, we are all working toward the same goal," Dr. MacPhee said.

At UBC, the pass rate for the 44 students who have taken the exam to date is 97.7 per cent – about the same as under the previous regime, she said, adding that it will take time to determine trends resulting from the new exam.

At the University of Saskatchewan, preliminary results showed an average pass rate of 79 per cent.

Lorna Butler, dean of nursing at the University of Saskatchewan, said those results were promising, but that, like many stakeholders, she would like to see some changes in the process, including more Canadian registered nurses involved in writing questions for the exam.

Dr. Tapp of the University of Calgary said she hoped the test results would spur regulators to re-evaluate the exam – without shaking public confidence in nurses.

"We have every confidence that Canadian nursing graduates are just as competent as they were last year," she said. "We evaluate our students constantly, with a lot of different methods; we don't want to undermine confidence in our nurses.

"We know that the only thing that's really changed is the examination."

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