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The Globe and Mail

Why a U.S. licensing exam shouldn’t regulate Canadian nurses

Kirsten Woodend is dean of the Trent/Fleming School of Nursing, and president of the Canadian Association of Schools of Nursing.


In January, 2015, changes were made to the "entry to practise" exam for Canadian nurses, which is taken by graduates of Canadian nursing programs after completing their four-year university program and obtaining more than 1,300 hours of clinical experience.

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The test was changed from the previous Canadian Registered Nurse Exam to a U.S. licensing exam, known as NCLEX-RN. In September, 2015, we saw the results of this shift: failure rates as high as 30 per cent that are keeping fully educated nurses from working in the field for which they are trained and qualified.

The introduction of the new exam has been controversial; New Brunswick is suspending the need to pass it for two years, while adjustments are made.

In defending the new exam, nursing regulators such as the College of Nurses of Ontario say passing the test is a matter of ensuring patient safety. This claim has no basis in fact. There is no published evidence that passing the test predicts safe practice. And trying to correlate high failure rates of the exam with increasing the quality of Canada's nursing professionals is flawed and misleading.

Evidence abounds that patients cared for by nurses with baccalaureate degrees have better outcomes, including lower surgical mortality. One study, conducted in 300 hospitals in nine European countries and including data on more than 400,000 surgical patients, found that for every 10-per-cent increase in the proportion of baccalaureate-prepared nurses, there was a 7-per-cent decrease in 30-day mortality. This is relevant because the four-year baccalaureate in nursing is the entry-to-practice requirement in most of Canada, including Ontario. In the United States, nurses can practise with a two-year diploma or an associate degree, as long as they pass the exam.

The evidence is conclusive: Baccalaureate-prepared nurses provide better outcomes, and thus improve patient safety. So if the U.S. exam is meant to be a predictor of safety, we would expect pass rates for baccalaureate-prepared nurses to be significantly higher than for diploma- or associate-degree nurses. They aren't. Baccalaureate-prepared nurses in the United States do not have higher pass rates on the exam; their pass rates are nearly identical to diploma-prepared nurses. If the exam doesn't discriminate between the nurses shown to offer better patient outcomes and the others, then it is not a predictor of patient safety.

In Ontario, failing the exam means practising nurses and recent graduates lose their temporary licence to practise until they successfully rewrite the exam. This exam is not only keeping fully educated nurses from joining the work force, it is also robbing students who have invested four years of preparation and thousands of dollars in their education of their future.

Will we continue to ignore the data and watch as more nursing graduates fail this exam? This is too high a price to pay, both for those who are unable to practise and for our health-care system, especially considering that the exam barring them will not improve safety.

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Graduates of Canada's rigorous four-year nursing baccalaureate programs have long been in demand around the world, including in the United States, a testament to the high quality of their education. The quality of Canada's nursing education, and of its nurses, did not change in 2015. The exam did.

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