Changing nurse licensing examinations: media analysis and implications of the Canadian experience

Aim This study examines perceptions of the implementation of National Council Licensing Examination in Canada through a content analysis of articles in the media. Background Public opinions of nur…

Abstract

Aim

This study examines perceptions of the implementation of National Council Licensing Examination in Canada through a content analysis of articles in the media.

Background

Public opinions of nursing in the media have been acknowledged as important for the profession, specifically in relation to their portrayal of nursing.

Introduction

The Canadian Council of Registered Nurse Regulators began using the US‐based National Council Licensing Examination as entry examination (also known widely as NCLEX) for Canada’s registered nurses, discontinuing the previous Canadian Registered Nurse Examination in 2015.

Methods

A qualitative content analysis was conducted of media reports that emerged following adoption of the National Council Licensing Examination in Canada, and highlight the image of nursing portrayed in the media during this key regulatory policy change.

Results

Release of the examination results for the first three quarters of 2015 identified a much lower overall Canadian pass rate than with the previous exam. Media reports highlight differences in perception of the examination between Canadian regulators and other stakeholders in the context of the examination experiences reported and test results. Issues around applicability of the examination to Canadian nursing practice, curriculum alignment, language translation concerns and stakeholder engagement were identified.

Discussion

The implementation of the National Council Licensing Examination in Canada highlighted lack of communication among nursing stakeholders in the country.

Conclusions

Most of the media reporting has been negative and poses a reputational risk to the Canadian nursing profession.

Implications for Nursing Policy

This change in the licensing requirement has significant policy implications for nursing in Canada and globally. Issues such as appropriate examination translation, access to appropriate test preparation materials, assurance that the examination reflects distinctive aspects of a country’s healthcare system and the need for stakeholder engagement were identified.

Introduction

Public opinions of nursing in the media have been acknowledged as important for the profession, specifically in relation to their portrayal of nursing roles (Donelan et al.


2008

; McGillis Hall & Kashin


2015

; Summers & Summers


2014

). To date, much of the literature has challenged the stereotypical images of nursing often reinforced in the media, with little attention directed towards the effect that media portrayals might have on the nursing workforce and thus the future of the nursing profession. Public opinion polls globally indicate that nurses are one of the most trusted and highly valued professional groups in society (Gallup


2015

; Roy Morgan Research


2016

; The Kings Fund


2015

). Thus, policy or practice changes in a country that may influence media representations of nurses are important considerations for the profession.

In Canada, nursing regulatory bodies in the provinces and territories (political and administrative subdivision of the nation) are accountable for the protection of the public by making certain registered nurses (RNs) are ‘safe, competent, compassionate and ethical practitioners’ as self‐regulated professionals [Canadian Council of Registered Nurse Regulators (CCRNR)


2016a

]. To determine their level of competence for licensure, potential nurses must pass an examination before entering practice. The Canadian Registered Nurse Examination (CRNE), a paper‐based examination offered three times a year, had been used by most Canadian provinces and territories for licensing Canada’s nurses since 1970. Exceptions are Quebec with a francophone population using its own professional licensing examination, and the Yukon, where no nursing schools exist, and which accepts RN licences received from other jurisdictions. In January 2015, Canadian nursing regulatory bodies adopted the US‐based National Council for Licensure Examination for Registered Nurses (NCLEX) as the entry examination for Canada’s registered nurses, offered through the National Council of State Boards of Nursing (NCSBN) [College of Nurses of Ontario (CNO)


2011

; NCSBN


2011

].

Serving as the first time the NCLEX is being used to license RNs in a country outside the United States, the examination was selected by Canadian regulators: ‘after identifying the need for an exam that employs the latest advances in testing technology to enhance test security, increase(s) accessibility to the exam by offering year‐round testing, provide(s) timely results and allow(s) for precise assessment of an individual candidate’s performance’ (NCSBN


2014a

).

The decision to change the vendor and type of licensing examination was met with considerable concern from a number of stakeholder groups across Canada. These included the Canadian Nurses Association (CNA), the Council of Ontario University Programs of Nursing (COUPN), the Canadian Association of Schools of Nursing (CASN), the Canadian Nursing Students Association (CNSA), the Canadian Federation of Nurses Unions (CFNU), the Academy of Canadian Executive Nurses (ACEN) and the Registered Nurses’ Association of Ontario (RNAO), each of which wrote formal letters to Canadian regulatory groups or government officials and/or posted statements on their websites outlining their concerns. Several issues were raised: a)

applicability of US examination to context of Canadian nursing practice –

it was perceived that NCLEX would not appropriately assess competencies demanded by Canadian nursing and the Canadian health system; b)

curriculum alignment

– there was concern that NCLEX would not reflect or engage with the existing curriculum in Canadian schools of nursing; c)

confirmation that the examination would test adequately in both official languages (English and French) in Canada

– Canada is officially bilingual (English and French); thus, NCLEX had to be available in French as well, meaning that the English examination had to be well‐translated into French (with review by Canadian French‐speaking nurses) and had to reflect Canadian practice; and d)

lack of stakeholder engagement

– educators and other key nursing groups in Canada were not consulted on the decision to adopt the NCLEX.

While some demanded reconsideration of the decision to adopt the NCLEX (Grinspun & McNeil


2011

), most stakeholders articulated interest in actively engaging with Canadian regulators in the transition to the new examination (ACEN


2012

; Baker


2012

; Baker & Dallaire


2012

; CNA


2011

; CASN


2011

; Jolicoeur


2011

; Tompkins


2011

; Tompkins & DeLuca


2012

). Despite these offers, they were not included in that process (Canadian Association of Schools of Nursing


2015a

; CBC News


2015b

; Simes


2015

; University of Calgary


2015

).

Background

Adopting the NCLEX‐RN in Canada

Regulatory groups

Canadian nurse regulators worked with the US NCSBN in preparation for adopting the NCLEX, several years before formally selecting it as the vendor for the exam. In 2009, two of the provincial nursing regulatory bodies in Ontario and British Columbia (Canada) initiated studies with samples of Canadian RNs comparing their perceptions of 142 RN activities in the United States to those of the two provinces (NCSBN


2010a

,


b

). The results of both activity studies indicated participants in the Canadian and US samples view entry‐level practice similarly. Both reports concluded that regulators of the two Canadian provinces ‘may want to consider further collaboration on a joint licensure examination, which could enhance licensure portability and benefit both the US, and (Ontario/British Columbia), and ultimately the public’ (National Council of State Boards of Nursing


2010a

,


b

). These two reports were released in July 2010, close to a year and a half before the Canadian regulators selected the NCSBN as vendor for the licensing exam.

Once the NCLEX was selected for use in Canada, the NCSBN conducted a Canadian practice analysis in 2013 (NCSBN


2014b

). This analysis concluded that Canadian activity ratings were similar to those found in their 2011 practice analysis with US nurses, and thus ‘provides evidence to support’ the use of the NCLEX examination in Canada (National Council of State Boards of Nursing


2014b

). A more recent practice analysis comparing ‘current Canadian RN practice with the 2013 Canadian RN practice’ was conducted on a sample of both US and Canadian nurses in 2013 and 2014 (National Council of State Boards of Nursing


2015

). The report indicates ‘some (…) survey questions were slightly modified to accommodate different terminologies used in Canada (e.g. ethnicity)’ (NCSBN


2015

), concluding that the reliability of the survey is good and ‘there was evidence to support the validity of the activity statement ratings’ (National Council of State Boards of Nursing


2015

).

Stakeholder groups

Following the December 2011 regulator announcement of the examination change, Canadian nurse educators worked to develop resources and information to support faculty and schools of nursing in the examination transition. In particular, CASN developed a fact sheet outlining key differences in the exams for nurse educators in Canada (CASN


2012a

) and conducted educational webinars for nurse educators. The webinars addressed the fact that the NCLEX examination focused on acute care settings and technical aspects of care that students needed to practice taking computer adaptive tests using variable question formats, as well as understand that the length of an individual’s examination does not necessarily relate to passing or failing it. The webinars were also used to encourage both faculty and students to become familiar with the test‐taking procedures (Canadian Association of Schools of Nursing


2012a

). At its annual fall meeting in 2012, CASN provided an overview comparing the CRNE and the NCLEX to assist nurse educators in understanding differences expected (CASN


2012b

). CASN also provided information on preparatory resources available from a variety of companies as a guide for nursing faculty (CASN


2012c

). The organization also surveyed Canadian schools of nursing, identifying strategies used to prepare students for the NCLEX in a briefing note. Strategies included curriculum assessment, faculty and student development, and specific testing strategies that could be employed (CASN


2014

).

Similarly, nursing stakeholder groups, such as the CNSA, posted website information to guide students, offered information sessions to support them in examination preparation and directed students to the regulator website for further information. In addition, a number of nursing faculty members across Canada attended conferences hosted by the US‐based NCSBN on the NCLEX.

Despite these efforts, the release of the Canadian NCLEX examination results for the first three quarters of 2015 identified an overall Canadian pass rate of only 70% (CCRNR


2015a

), much lower than in previous years with the CRNE. This resulted in a great deal of concern across the country as evidenced in the many print, television, radio articles and online blogs that emerged (CASN


2015a

; CNA 2015; Medves


2015

; Woodend & Medves


2015

).

Aim of the study

This study examines perceptions of the implementation of National Council Licensing Examination in Canada through a content analysis of articles in the media.

Methods

Design

The content analysis was conducted of the 2015 media reports that emerged related to adoption of the NCLEX in Canada and highlights the image of nursing portrayed in the media during this key regulatory policy change in the country. Media analysis is a well‐established form of content analysis that focuses on identifying the ‘likely meanings to and impacts on audiences’ of text in the media (Macnamara


2005

).

Sample

Media content in this analysis included all forms of Canadian media (newspaper, radio, television, blogs) that were found for a 6‐month period (1 July 2015 and 31 December 2015) around the time of public release of the Canadian pass rates for the first time on this new exam. This timeframe was selected to ensure the form, duration and content of media sampled were relevant for the analysis (Newbold et al.


2002

).

Data collection

The media items were identified through regular Google searches for news about the NCLEX examination in Canada and scanning of major media and health/nursing blogs.

Ethical considerations

Institutional ethical approval was not required for this study as the authors reviewed material already present in the public domain.

Data analysis

Each of the media reports were read by four members of the research team, and independently categorized into initial descriptive themes sorted by their main topics. The team members conferred and discussed the themes, dealing with inconsistencies that emerged and generated a set of consistent codes in an iterative and reflexive manner (Sandelowski


2000

). Media reports were read and re‐read carefully using a process that was reflective and interactive to verify both the informational content and reporting in the media.

Validity and reliability/rigour

Rigour was ensured throughout the study by paying attention to trustworthiness through engagement with the data, debriefing and use of audit trails (Lincoln & Guba


1985

). Objectivity or intersubjectivity was attained through selection of a representative sample of the media (Macnamara


2005

). Reliability was maximized through the use of multiple team members in coding of the media content analysis (Macnamara


2005

).

Results

Forty‐eight media reports emerged in the fall of 2015, the majority after the mid‐year student NCLEX results in Canada were reported (Canadian Council of Registered Nurse Regulators


2015a

). Analysis of these documents demonstrates that many of the original concerns raised by Canadian stakeholders 4 years earlier when the announcement of the adoption of the NCLEX in Canada was made had now become a reality. In particular, concerns about the applicability of the NCLEX to test Canadian nursing practice, curriculum alignment, appropriate translation of the examination into French and the engagement of key stakeholders in the implementation of the examination were borne out. Data from the media reports are presented in the context of the core themes identified by the research team.

NCLEX applicability to Canada

Many media reports challenged whether the NCLEX questions are applicable to the Canadian healthcare context and appropriately test entry‐to‐practice competencies of Canadian nurses. One of the first newspaper reports a letter received from a student who passed the NCLEX at a university where a large number of graduates failed the examination (Lundmark


2015

). The student indicated the examination had questions on it ‘about medications that were not available in Canada and referred to positions that don’t exist in the Canadian health‐care system’ (Lundmark


2015

). As a union official described ‘medications sometimes have different names in the two countries. Students complained the math was in imperial measure and Canada has been on the metric system for more than three decades’ (Blizzard


2015a

).

Similarly, a nursing Dean reported ‘graduates encountered several questions regarding the American health‐care system that aren’t applicable to Canadian nursing practices’ (Simes


2015

). These reports were challenged by regulators who suggested that ‘there’s no evidence to support that claim ‐ there was no American or inappropriate content (in the exam), adding a panel looked over the exam to ensure there were no biases’ (Simes


2015

). In a further interview with Canada’s largest national newspaper, this same Dean asserted that ‘students told her they encountered questions that referred to Obamacare’ (Stueck


2015

). Canada’s regulatory council ‘tried to counter concerns that the NCLEX is an American test’ by posting information on its website clarifying that ‘those taking the exam would not be asked questions about the American health‐care system or see other American content on the exam’ (Stueck


2015

).

The president of the association representing Canadian nursing schools highlighted the disparities that exist on this issue. ‘While the new entry‐to‐practice exam was supposed to be adapted to Canadian requirements, what has happened instead is that Canadian schools are having to do their best to prepare their students to pass an American exam that fails to address the Canadian context’. (Canadian Association of Schools of Nursing


2015a

). However, the president of Canada’s national regulatory group denied this: ‘It’s not an American test and it’s not a Canadian test ‐ it’s a nursing exam’. (Blizzard


2015a

). Other regulators indicate ‘it’s not an American exam, it’s a North American exam’ (Mayer


2015

), and ‘there was an effort made to eliminate American cultural or jurisdictional biases that may have crept into the exam. Where they were found, they were removed’ (Kusch


2015

).

Curriculum alignment

Canadian educators were also concerned that the NCLEX would not be aligned with the nursing curriculum taught in Canada. Nurse leaders in healthcare institutions reinforce that ‘the problem is not the training of the nurses, but rather the structure of the exam’ (Grant


2015

). Concern from the public was evident in editorial letters to Canadian newspapers asking the regulatory college to ‘justify an exam that does not reflect the curriculum they (students) have studied for the past three to 4 years’ (Campbell


2015

). Canadian schools of nursing are ‘concerned the faculty will have to change its curriculum to meet the new test’s requirements. It’s an American exam not based on Canadian competencies. I don’t think it’s right for us to teach to an “American exam”’ (Simes


2015

).

A nursing Dean explains ‘We think that the Canadian nursing curriculum has a global reputation for producing top notch nurses and it’s based on competencies that have been identified by consensus across the country’ (Laderas


2015

). A graduate nurse who failed the examination interviewed on national television highlighted this further stating ‘the American schools teach towards the NCLEX’; ‘Their entire lectures are based on what you are going to be writing on the NCLEX exam’ (CTV News


2015b

). Canadian schools of nursing are adamant that ‘it is inappropriate for an American exam to be driving the focus of the curriculum in Canadian schools’ (Canadian Association of Schools of Nursing


2015a

). A government health minister agreed, suggesting that ‘I think we all agree that the exam that a health‐care practitioner should take in this province should reflect the curriculum that they’re taught and that it should be a useful tool to measure their preparedness for entering the workforce’ (Blizzard


2015b

).

Examination translation

Educators sought assurances that the NCLEX would adequately test graduates in both of Canada’s official languages – English and French – maintaining the previous standards in the country. These ensured the RN entry‐to‐practice examination contained questions developed and translations reviewed by Canadian French‐language‐speaking nurses.

Canadian educators reported that students in French‐language schools expressed considerable concern about both ‘the quality of the French language version of the test and the fact that much of the test prep(aratory) materials that have been developed to support writers on the NCLEX exist only in English’ (Canadian Association of Schools of Nursing


2015a

). Francophone students ‘…denounced the quality of the translation of the exam. Many questions were translated in French which was poor, so that the intention of the testers was blurred. It is as if we were the guinea pig group to assess whether the NCLEX exam is appropriate for the type of training we have received’ (Delattre


2015

).

Francophone students from another province gave similar comments. ‘Most of the time I didn’t understand what they were saying. I’m French – hardcore French – and I was like ‘What are you asking me?”’ (Crawford


2015a

). The student’s mother added that ‘It looks like they used Google translate’ (Crawford


2015a

). A faculty member observed, ‘We do know that some Francophone students opted to write the NCLEX in English because they did not trust the translation of the questions. We also know of some francophone students who struggled with the French version of the NCLEX who are currently wondering whether they should retake the exam in English’ (Crawford


2015a

). Canadian educators report that ‘there(is) absolutely no market interest from American corporations to develop French‐language prep(aratory) aids’ (Crawford


2015b

).

This varies considerably from the perspectives of Canadian nurse regulators who responded to student comments indicating ‘the exam provider, the NCSBN, has ensured that the questions are translated into Canadian French by experts and revised by bilingual nurses’ (Delattre


2015

). CCRNR states that ‘the number of French‐language writers of the exam is currently too low to provide reliable data. However, the information we do have suggests that the French translation of the NCLEX is performing similarly to the English version in terms of average response time and response patterns’ (CCRNR


2015b

). The regulators later identify that ‘we are working with a Canadian translation panel made up of nurses and educators fluent in French and English who review exam items for language equivalency on an ongoing basis’ (Crawford


2015a

).

Lack of communication and stakeholder engagement

Little evidence of consultation by regulators is evident from the time the examination change was announced in 2011 until well after the Canadian media was replete with stories of nursing students failing the exam. Beginning in July of 2015, media outlets in different provinces began to carry stories citing high student failure rates (Fraser


2015

; Lundmark


2015

). Many reports were generated by hospitals or health authorities who were bearing the brunt of not being able to employ new nursing graduates, as many had failed the NCLEX (CTV News


2015a

; Fraser


2015

). Thus, the supply of new nurses was not meeting demand. When regulators provided comments in the news, these were limited, usually indicating that they ‘were unable to provide information’ on the number of failures as ‘it risks breaching their privacy, their confidentiality’ (Fraser


2015

).

As the reporting of failure rates continued to pervade the media, some regulators appeared to redirect the focus to the schools of nursing: ‘It’s too early to tell. There needs to be a very in‐depth analysis of the programs’ (CBC News


2015a

). In a further report to a news agency the next day, the same regulator indicated ‘she does not believe that the new computerized examination is to blame. (She) rather think(s) that students were perhaps not well enough prepared, or they were too stressed’ (RadioCanada


2015

).

Responses from Canada’s national nursing organizations and some individual provincial regulators were at times paradoxical. In one province where the success rate was 81% compared to 92% the previous year on the CRNE, the regulator confirmed that ‘based on the results, so far we are encouraged that this is a valid and reliable exam’ (CBC News


2015a

). In another province, where pass rates dropped from 89% to 68.7%, the regulator indicated ‘the implementation of the new exam has gone very smoothly’ (Mayer


2015

). Communications from some provincial regulatory groups also created a somewhat distorted image to the public. An e‐blast sent by one regulator was titled ‘NCLEX

prepares

new nursing graduates to provide safe and quality care to Nova Scotians’ (College of Registered Nurses of Nova Scotia


2015

). This conflicts with earlier assertions by regulators that the examination tests graduates only, while it is the nursing school programme that prepares them.

Perhaps as a result of the overwhelming negative attention evident in the media, Canadian regulators began to take a stronger position. The title of their news release in late September 2015 highlights this: ‘correcting inaccuracies about the new nursing exam’ (Canadian Council of Registered Nurse Regulators


2015b

). One regulatory group representing the Canadian province with the largest number of nursing graduates annually developed a brightly coloured poster labelled ‘The truth about the NCLEX‐RN for students’ (CNO


2015

). Posted on its website, it highlights questions, each of which have the word “false” stamped across them, including: ‘I’ll need to know about the American health care system, everyone is failing the NCLEX‐RN, it tests everything, and I only have one chance to pass’ (College of Nurses of Ontario


2015

).

Government leaders in this same province also responded. ‘The province’s minister of colleges and universities is adamant that graduates of Canadian nursing schools should be tested with a Canadian exam’ (Blizzard


2015b

). The minister specifies ‘our regulatory colleges, including the College of Nurses, should design a Canadian exam rather than borrowing something from other countries’ (Blizzard


2015b

). Results of a national public opinion poll produced similar sentiments with ‘four in five Canadians (80%) believe(ing) that nurses, like other Canadian health professionals, should be assessed using a test that is based on Canadian requirements’ (CASN


2015b

).

Canadian educators continue to voice concern that the NCLEX ‘memory‐based questions (have) spawned an industry of costly preparatory material designed to help students pass’ (Crawford


2015b

). ‘It worries us. It’s turning over the education of nurses to large multinational American‐based corporations’ (Crawford


2015b

).

Discussion

NCLEX applicability

While the NCSBN practice and activity analyses are described as comparing entry‐level nursing practice activities for nurses in Canada to those in the United States, media reports of Canada’s experience call into question whether these analyses alone provide enough evidence to support a non‐US country using the NCLEX as its entry‐to‐practice nurse licensing exam. Numerous examples from examination writers across different schools and jurisdictions in the country highlighted inappropriate examination content for the context of Canadian nursing practice (e.g. Obamacare, references to medications and nursing roles not found in Canada). All of these experiences were denied by the regulators.

At the same time, the messages provided by regulators in the media were inconsistent. In some cases, regulators indicated the examination tests nursing, rather than focusing on either Canadian or US content. In others, regulators stated the examination was North American, suggesting it represented both Canadian and American content. When discussing the 10%–20% decline in pass rates to media, regulators concluded the examination was valid and implementation had gone well. This lack of congruence may have caused stakeholders and the public to question the breadth of understanding Canada’s newly formed council of nurse regulators had of the content and focus of the questions on the NCLEX, and thus, its appropriateness for use in Canada.

Curriculum alignment

One of the greatest challenges identified by educators prior to the examination change was concern that the curriculum of Canadian schools of nursing was not structured around the NCLEX. Canadian schools of nursing feel strongly that teaching to a test and creating a curriculum around a specific examination is counterintuitive and not consistent with principles of curriculum development.

In fact, the 2012 NCSBN report comparing entry‐level RN competencies in Ontario, Canada, to those expected on entry to practice for US nurses identified a 93% relationship existed between the two countries on these competencies (CCRNR


2012

). However, ten discrepancies were noted including five competencies related to ‘demonstrate(s)ing knowledge about the structure of the healthcare system at a national/international level, provincial/territorial level, regional/municipal level, agency level, and clinical practice or program level’ (Canadian Council of Registered Nurse Regulators


2012

).

Some of the themes that emerged in the media reports appear directly related to this inconsistency. In addition, findings from this report differ substantially from a more recent analysis conducted by Canadian educators comparing Canadian RN competencies to the nursing activities listed in the NCLEX test plan that formed the basis of the examination content that Canada’s first examination takers wrote (CASN


2015c

). The Canadian report suggests that ‘only 35% of the competencies required by Canadian regulators are tested’ in the NCLEX, and that ‘many of the activities tested are based on legislation, policy or guidelines in the US, or American health care delivery’ (Canadian Association of Schools of Nursing


2015c

). This suggests more attention should be directed at ensuring the NCLEX is appropriate for testing the competence of nurses educated in Canadian educational institutions, rather than changing curriculum to fit the exam.

Examination translation

Despite Canadian regulators asserting that the NCLEX would be adequately translated into French, reports in the media highlight gaps in translation. While the media identifies that all Canadian examination writers faced challenges dealing with questionable American content, issues for Canada’s francophone writers appear to be compounded by what they perceive to be as the poor quality of examination translation.

Perhaps most disturbing was the fact that no preparatory materials were available in the French language. Thus, students attended a French language programme, yet were disadvantaged from other Canadian writers who had access to the wide array of NCLEX preparatory materials available in English, as none were available in French. This appears to discriminate against the fundamental rights of a Canadian citizen in a country that is bilingual (English and French).

The management of language translation with this examination caused perhaps the greatest concern in Canada, leading stakeholders to question whether the regulators had adequately prepared for their decision to adopt the US exam. Canadian regulators maintained support for the examination in media reports, commenting only to similarities in response times and patterns on examination questions for both English and French writers, rather than on the fundamental questions related to the quality of translation and the availability of appropriate preparatory materials to all Canadian writers.

Lack of communication and stakeholder engagement

One of the most prevalent themes evident throughout the media reports is the poor communication between the relevant stakeholders that should be involved in a change of this nature. Stakeholders were unaware that Canadian regulators had been working with the US‐based NCSBN on key preliminary activities conducted to lay the groundwork for adoption of the NCLEX examination in Canada (e.g. activity and practice analysis). These activities undertaken a year and a half prior to their selection as the vendor for the Canadian entry‐to‐practice examination suggests to stakeholders that the decision had been made years in advance. This is further evidenced in the results of these reports which suggest collaboration on a joint licensing examination.

In addition, nurse educators identified to the media that they were initially informed by the regulators that there would be a Canadian version of the NCLEX developed for use in Canada. As evidenced in the media reports, there is only one exam, the same for all potential registrants from Canada and the United States.

This lack of transparency and engagement between regulators and other nursing stakeholders may have influenced the tremendous media attention that emerged, with educators, students, family members, government, unions and other nursing leaders in Canada, describing their experiences with the NCLEX. Titles of media reports portray a profession in disharmony with limited communication among stakeholder groups. This negative image is uncharacteristic of the nursing profession, and the impact and long‐term repercussions of these depictions of the Canadian nursing workforce have yet to be seen. The reports provide evidence of students approaching media outlets to tell their personal stories, nursing leaders describing the direct impact on healthcare settings of losing new graduates they had planned to hire, and educators in schools of nursing discussing the challenges of preparing students for an examination for which they have had little or no communication or engagement in either the selection or implementation process.

Release of the final examination results for the full year in March 2016 reinforced many of the concerns identified by the media, when an unprecedented low national pass rate of 69% was announced (CCRNR


2016b

). In addition, recent research conducted with 202 Canadian nursing graduates who wrote the NCLEX in 2015 identified several themes consistent with those found in the media including the examination focus on American context and content, concerns with French‐language translation materials and lack of communication and engagement by the regulators (McGillis Hall et al.


2016

).

Conclusion

The implementation of the NCLEX in Canada has caused a great deal of friction among nursing regulators and stakeholders in the country. Most of the media reporting has been negative and poses a serious reputational risk to the Canadian nursing profession. Canada’s experience calls into question the scope of power held by individual regulatory bodies, in a self‐regulating profession such as nursing. In addition, their accountability to relevant stakeholders in any proposed changes and their implementation requires careful consideration.

Policy implications

The experience of implementation of the US‐based NCLEX nurse examination for licensing in Canada highlights the need for a more detailed assessment of the examination to determine its applicability for use in the broader international context. Other countries considering adoption of the NCLEX for licensing their nurses can learn from Canada’s experience and ensure issues such as appropriate examination translation (as needed) and access to appropriate test preparation materials are provided. In addition, particular attention should be paid to ensuring the examination content reflects distinctive aspects of a country’s healthcare system; and consistency in medication terminology, availability and use; as well as differing scopes of practice and care provider roles between the countries.

In addition, serious consideration at a national level of the breadth of curricular revisions required by nursing schools to ensure students are adequately prepared to pass this examination is needed. More importantly, principles of curriculum development should be reassessed and considered in models utilized in adapting to this change. Greater involvement of nursing education institutions in the early stages of adopting an entry‐to‐practice examination supplied by a foreign entity would assist in ensuring examination content addresses a country’s (or other licensing district) clinical and practice competence needs.

From a policy perspective internationally, there is an obvious need to continue to monitor and evaluate the move to the NCLEX examination in Canada. It is essential that Canadian regulators work collaboratively with educators in the future in a meaningful way to ensure that a safe transition and desired harmonization of the examination can be achieved. The same would be necessary for other countries, who would require stakeholder engagement in this change to optimize successful implementation.

As suggested by David Benton, the Chief Executive Officer of the NCSBN, while discussing how he leads 50 state boards of nursing in the United States to work together as a group, there is a need to recognize ‘that you simply cannot take a one‐size‐fits‐all solution but you need to tailor the solution to the context, whether that be the political environment, educational system, or the cultural climate’ (Nickitas


2016

). This media analysis provides an example of how policy or practice changes in a country may influence media representations of nurses. Change, especially when implemented without stakeholder engagement, has consequences, which can lead to negative media coverage and negative perceptions of professionals.

Author contributions

Study design and Study supervision: LM

Data collection: JK

Data analysis: LM, ML, JK, CW and JM

Performed manuscript writing and critical revisions for important intellectual content: LM and ML


References


Academy of Canadian Executive Nurses Executive Committee

(

2012

)

[Message to membership re: computer based RN entrance exam February 21, 2012]

. Copy in possession of Linda McGillis Hall.


Google Scholar


Baker, C.

(

2012

)

[Letter to membership of Canadian Association of Schools of Nursing: May 2, 2012]

. Copy in possession of Linda McGillis Hall.


Google Scholar


Baker, C.

&

Dallaire, C.

(

2012

)

[Letter to National Council of Regulators]

. Copy in possession of Linda McGillis Hall.


Google Scholar


Blizzard, C.

(

2015a

)

Ontario nurses angered by ‘U.S.’ licensing exam

.

Toronto Sun

. 18 September 2015. Available at:

http://www.torontosun.com/2015/09/18/ontario-nurses-angered-by-us-licensing-exam

(accessed 20 September 2015)


Google Scholar


Blizzard, C.

(

2015b

)

Canadian nurses should be judged by Canadian standards

.

Toronto Sun

. 29 September 2015. Available at:

http://www.torontosun.com/2015/09/29/canadian-nurses-should-be-judged-by-canadian-standards

(accessed 30 September 2015).


Google Scholar


Campbell, D.

(

2015

)

Nurses college challenged to address exam issue

.

Chronicle Journal

. 20 July 2015. Available at:

http://www.chroniclejournal.com/opinion/letters_to_editor/nurses-college-challenged-to-address-exam-issue/article_92dd536c-2cc6-11e5-aeb6-bf91a5c6d31c.html

(accessed 21 July 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2011

)

CASN position statement: proposed new entry‐to‐practice nursing exam

. Available at:

http://www.casn.ca/2014/10/proposed-new-entry-practice-nursing-exam-position-statement/(accessed

21 July 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2012a

)

Considerations regarding the NCLEX‐RN for nurse educators in Canada

. Available at:

http://www.casn.ca/2014/12/considerations-regarding-2015-nclex-rn-canadian-nurse-educators/(accessed

21 July 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2012b

)

CRNE to NCLEX‐RN: CASN’s role on the road to 2015

. Available at:

http://www.casn.ca/2014/12/crne-nclex-rn-powerpoint/(accessed

21 July 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2012c

)

Companies offering NCLEX‐RN preparation resources

. Copy in possession of Linda McGillis Hall.


Google Scholar


Canadian Association of Schools of Nursing

(

2014

)

Transitioning to the NCLEX‐RN. Briefing note. Repertoire of strategies

. Available at:

http://casn.ca/wp-content/uploads/2014/12/TransitioningtotheNCLEX.pdf

(accessed 21 July 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2015a

)

New American entry‐to‐practice exam a failure for Canadian nursing students and for Canada

. [Press Release] Available at:

http://www.casn.ca/2015/09/new-american-entry-to-practice-exam-a-failure-for-canadian-nursing-students-and-for-canada-ottawa-sept-9-2015/

. (accessed 10 September 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2015b

)

Four in five Canadians believe our nurses should be assessed using a test based on Canadian requirements (news release)

. Available at:

http://www.newswire.ca/news-releases/four-in-five-canadians-believe-our-nurses-should-be-assessed-using-a-test-based-on-canadian-requirements-532430752.html

(accessed 14 October 2015).


Google Scholar


Canadian Association of Schools of Nursing

(

2015c

)

The NCLEX‐RN is an American exam

. Available at:

http://www.casn.ca/wp-content/uploads/2015/11/NCLEX-an-American-Exam-Nov-251.pdf

(accessed 30 November 2015).


Google Scholar


Canadian Council of Registered Nurse Regulators

(

2012

)

Canada – NCSBN entry‐level competency statement comparison

. Available at:

http://www.ccrnr.ca/assets/report-on-canada-ncsbn-entry-level-rn-competency-statement-comparison.pdf

(accessed 10 September 2015).


Google Scholar


Canadian Council of Registered Nurse Regulators

(

2015a

).

Canadian NCLEX‐RN passing rates

. Available at:

http://www.ccrnr.ca/assets/main-report-canadian-nclex-rn-pass-rate-analysis-q1-q2-2015.pdf

(accessed 9 September 2015).


Google Scholar


Canadian Council of Registered Nurse Regulators

(

2015b

).

Correcting inaccuracies about the new nursing exam (press release)

. Available at:

http://www.ccrnr.ca/assets/ccrnr—nclex-press-release-sept-23-2015–final.pdf

(accessed 23 September 2015).


Google Scholar


Canadian Council of Registered Nurse Regulators

(

2016a

)

Competencies in the context of entry‐level registered nurse practice

. Available at:

http://www.ccrnr.ca/entry-to-practice.html

. (accessed 17 December 2016).


Google Scholar


Canadian Council of Registered Nurse Regulators

(

2016b

)

NCLEX RN 2015: Canadian results

. Available at:

http://www.ccrnr.ca/assets/2015-ccrnr-report-finalfor-release-31-mar-2016.pdf

. (accessed 31 March 2016).


Google Scholar


Canadian Nurses Association

(

2011

)

Canadian Nurses Shocked at American Announcement [Media Release]

. Canadian Nurses Association. Available at:

https://www.cna-aiic.ca/en/news-room/news-releases/2011/canadian-nurses-shocked-at-american-announcement

. (accessed 23 September 2015).


Google Scholar


Canadian Nurses Association

(

2015

)

Nursing profession concerned with first NCLEX‐RN results

. [Media release] Available at:

https://www.cna-aiic.ca/en/news-room/news-releases/2015/nursing-profession-concerned-with-first-nclex-rn-results

. (accessed 12 September 2015).


Google Scholar


CBC News

(

2015a

)

New Brunswick nurses 47% fail rate on NCLEX‐RN

.

CBC News

. 8 September 2015. Available at:

http://www.cbc.ca/news/canada/new-brunswick/new-brunswick-nurses-47-fail-rate-on-nclex-rn-1.3220190

(accessed 9 September 2015).


Google Scholar


CBC News

(

2015b

)

NCLEX nursing exam fail rate has Alberta graduates, universities concerned

.

CBC News

. 10 September 2015. Available at:

http://www.cbc.ca/news/canada/calgary/nclex-nursing-exam-fail-rate-has-alberta-graduates-universities-concerned-1.3221965

(accessed 11 September 2015).


Google Scholar


College of Nurses of Ontario

(

2011

)

New partnership brings computer‐based RN exam to Canada (news release)

. Available at:

http://www.cno.org/en/news/2012/06/nursing-regulators-announce-examination-partnership/(accessed

21 July 2015).


Google Scholar


College of Nurses of Ontario

(

2015

)

The truth about the NCLEX‐RN for students

. Available at:

http://www.cno.org/globalassets/3-becomeanurse/nclex/truth-about-nclex-rn.pdf

(accessed 2 March 2015).


Google Scholar


College of Registered Nurses of Nova Scotia

(

2015

)

NCLEX‐RN prepares new nursing graduates to provide safe and quality nursing care to Nova Scotians

. Available at:

http://crnns.ca/news/nclex-rn-prepares-new-nursing-graduates-to-provide-safe-and-quality-nursing-care-to-nova-scotians/(accessed

9 September 2015).


Google Scholar


Crawford, B.

(

2015a

)

It looks like they used Google Translate: U.S. tripping up Canadian nursing students

.

National Post

. 16 October 2015.Available at:

http://news.nationalpost.com/news/canada/it-looks-like-they-used-google-translate-u-s-test-tripping-u

p‐canadian‐nursing‐students (accessed 16 October 2015).


Google Scholar


Crawford, B.

(

2015b

)

Replace U.S.‐designed nursing exam, educators urge

.

Ottawa Citizen

. 16 October 2015. Available at:

http://ottawacitizen.com/news/local-news/replace-u-s-designed-nursing-exam-educators-urge

(accessed 23 October 2015).


Google Scholar


CTV News

(

2015a

)

New U.S.‐based exam has nursing students failing at alarming rate

.

CTV News

. 16 July 2015. Available at:

http://www.tbnewswatch.com/News/373345/New_U.S.-based_exam_has_nursing_students_failing_at_alarming_rate

(accessed 17 July 2015)


Google Scholar


CTV News

(

2015b

)

Concerns raised over new U.S. nursing exam as pass rates plummet in Canada

.

CTV News

. 17 September 2015. Available at:

http://www.ctvnews.ca/health/concerns-raised-over-new-u-s-nursing-exam-as-pass-rates-plummet-in-canada-1.2567794

(accessed 18 September 2015).


Google Scholar


Delattre, S.

(

2015

)

Nursing exam: new Brunswick last in class (in French)

. Available at:

http://www.acadienouvelle.com/actualites/2015/09/09/examen-dinfirmieres-le-n-b-dernier-de-classe/?pgnc=1

(accessed 10 September 2015)


Google Scholar


Donelan, K.

, et al. (

2008

)

Public perceptions of nursing careers: the influence of the media and nursing shortages

.

Nursing Economics

,

26

(

3

),

143



150

, 165.


Fraser, E.

(

2015

)

Almost half of nursing graduates flunk new exam

.

Telegraph‐Journal (New Brunswick)

, pp. A1.


Google Scholar


Gallup

(

2015

).

Americans’ faith in honesty, ethics of police rebounds

. Available at:

http://www.gallup.com/poll/187874/americans-faith-honesty-ethics-police-rebounds.aspx?g_source=Social+Issues&g_medium=newsfeed&g_campaign=tiles

(accessed 1 September 2016).


Google Scholar


Grant, R.

(

2015

)

Failure rate for new exam further complicates nursing shortage in Halifax

.

CTV News

. 29 August 2015. Available at:

http://atlantic.ctvnews.ca/failure-rate-for-new-exam-further-complicates-nursing-shortage-in-halifax-1.2537356

(accessed 29 August, 2015).


Google Scholar


Grinspun, D.

&

McNeil, D.

(

2011

).

[Letter to Kris Voycey, President, & Anne Coghlan, Executive Director, College of Nurses of Ontario, December 13, 2011]

. Available at:

http://rnao.ca/policy/submissions/letter-cno-re-rn-exam

(accessed 2 January 2013).


Google Scholar


Jolicoeur, E.

,

Canadian Nursing Students Association

(

2011

)

[Letter to Clemence Dallaire and CASN Board of Directors, December 19, 2011]

. Copy in possession of Linda McGillis Hall.


Google Scholar


Kusch, L.

(

2015

)

U.S. Centric test imposed on nurses

.

Winnipeg Free Press

. 17 October 2015. Available at:

http://www.winnipegfreepress.com/local/us-centric-test-imposed-on-nurses-333488161.html

(accessed 18 October 2015).


Google Scholar


Laderas, C.

(

2015

)

Nursing faculty official says “American” exam to blame for failing students

.

660 News

. 10 September 2015. Available at:

http://www.660news.com/2015/09/10/nursing-faculty-official-says-american-exam-to-blame-for-failing-students/(accessed

1 September 2015).


Google Scholar


Lincoln, Y.S.

&

Guba, E.G.

(

1985

)

Naturalistic inquiry

. Sage,

Beverly Hills, CA

.


Crossref


Google Scholar


Lundmark, J.

(

2015

)

Exam stumps nursing students

.

Chronicle Journal

. 15 July 2015. Available at:

http://www.chroniclejournal.com/news/local/exam-stumps-nursing-students/article_11b0f3c0-2aa5-11e5-a2d2-a398838f193b.html

(accessed 16 July 2015).


Google Scholar


Macnamara, J.

(

2005

)

Media content analysis: its uses; benefits and best practice methodology

.

Asia Pacific Public Relations Journal

,

6

(

1

),

1



34

.


Google Scholar


Mayer, F.

(

2015

)

Lower pass rate for new nursing exam stirs up controversy

.

The Gauntlet

. 11 September 2015. Available at:

http://www.thegauntlet.ca/lower-pass-rate-for-new-nursing-exam-stirs-up-controversy/(accessed

12 September 2015).


Google Scholar


McGillis Hall, L.

&

Kashin, J.

(

2015

)

Public understanding of the role of nurses during Ebola

.

Journal of Nursing Scholarship

,

48

(

1

),

1



7

. doi:

10.1111/jnu.12182

.


McGillis Hall, L.

,

Lalonde, M.

&

Kashin, J.

(

2016

)

People are failing! Something needs to be done: Canadian students’ experience with the NCLEX‐RN

.

Nurse Education Today

,

46

,

43



49

. doi:

10.1016/j.nedt.2016.08.022

.


Medves, J.

(

2015

)

Is it our job to educate RNs for Canada or for the United States?

Dean on Campus Blog, Queen’s University School of Medicine. Available at:

https://meds.queensu.ca/blog/?p=3113

(accessed 19 October 2015).


Google Scholar


National Council of State Boards of Nursing

(

2010a

)

NCSBN Research Brief. Volume 47. Report of Findings from the Comparison of Entry‐level Registered Nurses in the U.S. and Ontario, Canada

. Available at:

https://www.ncsbn.org/10_Ontario_Vol47_web.pdf

(accessed 21 July 2015).


Google Scholar


National Council of State Boards of Nursing

(

2010b

)

NCSBN Research Brief. Volume 48. Report of Findings from the Comparison of Entry‐level Registered Nurses in the U.S. and British Columbia, Canada

. Available at:

https://www.ncsbn.org/10_BC_Vol48_web.pdf

(accessed 21 July 2015).


Google Scholar


National Council of State Boards of Nursing

(

2011

)

NCSBN and Pearson VUE to bring NCLEX‐RN examination to Canada (news release)

. Available at:

http://www.pearsonvue.com/about/release/archive/11_12_08_nclex.asp


Google Scholar


National Council of State Boards of Nursing

(

2014a

). NCSBN opens registration for NCLEX in Canada. (News Release). Available at:

https://www.ncsbn.org/6655.htm

(accessed 12 September 2015).


Google Scholar


National Council of State Boards of Nursing

(

2014b

)

NCSBN Research Brief. Volume 60. 2013 Canadian RN Practice Analysis

. Available at:

https://www.ncsbn.org/14_Canadian_Practice_Analysis_vol60.pdf

(accessed 12 September 2015).


Google Scholar


National Council of State Boards of Nursing

(

2015

)

NCSBN Research Brief. Volume 62. 2014 RN Practice Analysis: Linking the NCLEX‐RN Examination to Practice

. US and Canada. Available at:

https://www.ncsbn.org/15_RN_Practice_Analysis_Vol62_web.pdf

(accessed 31 March 2016.


Google Scholar


Newbold, C.

,

Boyd‐Barrett, O.

&

VanDen Bulck, H.

(

2002

)

The Media Book

.

Arnold (Hodder Headline)

, London.


Google Scholar


Nickitas, D.M.

(

2016

)

Shifting the curve: an interview with David C. Benton

.

Nursing Economics

,

34

(

2

),

77



81

.


RadioCanada

(

2015

)

A new exam raises the failure rate of nursing graduates (in French)

.

Radio Canada

. 9 September 2015. Available at:

http://ici.radio-canada.ca/regions/atlantique/2015/09/08/016-test-examen-finissants-sciences-infirmieres-taux-reussite-echec.shtml

(accessed 10 September 2015).


Google Scholar


Roy Morgan Research

(

2016

)

Roy Morgan image of professions survey 2016: nurses still easily most highly regarded – followed by doctors, pharmacists and engineers

. Available at:

http://www.roymorgan.com/findings/6797-image-of-professions-2016-201605110031

(accessed on 1 September 2016).


Google Scholar


Sandelowski, M.

(

2000

)

Whatever happened to qualitative description?

Research in Nursing and Health

,

23

,

334



340

.


Simes, J.

(

2015

)

Low RN exam pass‐rate concerns University of Calgary

.

Metronews

. 9 September 2015. Available at:

http://www.metronews.ca/news/calgary/2015/09/09/rn-exam-pass-rate-concerns-university-of-calgary-nursing.html

(accessed 10 September 2015).


Google Scholar


Stueck, W.

(

2015

)

Fewer nursing students are passing the new national licensing exam

.

The Globe and Mail

. 9 September 2015. Available at:

http://www.theglobeandmail.com/news/british-columbia/fewer-nursing-students-are-passing-the-new-national-licensing-exam/article26297735/(accessed

10 September 2015).


Google Scholar


Summers, S.

&

Summers, H.J.

(

2014

)

Saving Lives: why the Media’s Portrayal of Nursing Puts us all at Risk

. Oxford University Press Canada,

Toronto, Canada

.


Crossref


Google Scholar


The King’s Fund

(

2015

)

Do the public still trust doctors and nurses?

Available at:

http://www.kingsfund.org.uk/blog/2015/12/public-trust-doctors-nurses

(accessed 1 September 2016).


Google Scholar


Tompkins, C.

(COUPN) (

2011

)

[Letter to Anne Coghlan, Executive Director, College of Nurses of Ontario, December 21, 2011]

. Copy in possession of Linda McGillis Hall.


Google Scholar


Tompkins, C.

&

DeLuca, S.

(

2012

)

[Letter to Kris Voycey, President, College of Nurses of Ontario, February 17, 2012]

. Copy in possession of Linda McGillis Hall.


Google Scholar


University of Calgary

(

2015

)

University of Calgary concerned with content of new Registered Nursing exam (press release)

. Available at:

http://www.marketwired.com/press-release/university-of-calgary-concerned-with-content-of-new-registered-nursing-exam-2054091.htm

(accessed 9 September 2015).


Google Scholar


Woodend, K.

&

Medves, J.

(

2015

)

Kristen Woodend and Jennifer Medves: we are failing our nurses

.

National Post

. 14 December 2015. Available at:

http://news.nationalpost.com/full-comment/kirsten-woodend-jennifer-medves-we-are-failing-our-nurses

. (accessed 15 December 2015).


Web of Science®


Google Scholar


Citing Literature

Source URL: Read More
The public content above was dynamically discovered – by graded relevancy to this site’s keyword domain name. Such discovery was by systematic attempts to filter for “Creative Commons“ re-use licensing and/or by Press Release distributions. “Source URL” states the content’s owner and/or publisher. When possible, this site references the content above to generate its value-add, the dynamic sentimental analysis below, which allows us to research global sentiments across a multitude of topics related to this site’s specific keyword domain name. Additionally, when possible, this site references the content above to provide on-demand (multilingual) translations and/or to power its “Read Article to Me” feature, which reads the content aloud to visitors. Where applicable, this site also auto-generates a “References” section, which appends the content above by listing all mentioned links. Views expressed in the content above are solely those of the author(s). We do not endorse, offer to sell, promote, recommend, or, otherwise, make any statement about the content above. We reference the content above for your “reading” entertainment purposes only. Review “DMCA & Terms”, at the bottom of this site, for terms of your access and use as well as for applicable DMCA take-down request.

Acquire this Domain
You can acquire this site’s domain name! We have nurtured its online marketing value by systematically curating this site by the domain’s relevant keywords. Explore our content network – you can advertise on each or rent vs. buy the domain. Buy@TLDtraders.com | Skype: TLDtraders | +1 (475) BUY-NAME (289 – 6263). Thousands search by this site’s exact keyword domain name! Most are sent here because search engines often love the keyword. This domain can be your 24/7 lead generator! If you own it, you could capture a large amount of online traffic for your niche. Stop wasting money on ads. Instead, buy this domain to gain a long-term marketing asset. If you can’t afford to buy then you can rent the domain.

About Us
We are Internet Investors, Developers, and Incubators- operating a content network of several thousand sites while federating 20+ eCommerce and SaaS startups. With our proprietary “inverted incubation” model, we leverage a portfolio of $15M+ in valued domains to impact online trends, traffic, and transactions. We use robotic process automation, machine learning, and other proprietary approaches to power our content network. Discover our work!

Share