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The NCLEX-RN and the future of French-language health-care services

A federal standing committee learns of ongoing concerns with the entry-to-practice nursing exam and the lack of French-language study resources

Sep 05, 2017, By: Virginia St-Denis

Concerns about the NCLEX-RN entry-to-practice exam have grown loud enough to be heard by the House of Commons standing committee on official languages.

Representatives from the Canadian Association of Schools of Nursing (CASN); the nursing schools at the Université de Moncton, University of Ottawa and Laurentian University; the College of Nurses of Ontario (CNO); and the Nurses Association of New Brunswick (NANB) testified during the committee’s May 9 meeting in Ottawa. They discussed the current problem, where they see it stems from, their concerns about the future and possible solutions.

Committee member and Liberal MP Paul Lefebvre brought the issue to the standing committee’s attention. While health and education fall under provincial and territorial jurisdiction, he said the federal government has an interest in the issue because it subsidizes some of the French health education programs across Canada.

“The standing committee on official languages is very worried about this situation. We just released a report on the new Official Languages Action Plan, and health plays a central role,” committee member and New Democratic Party MP François Choquette said. “When there are barriers that stand in the way of the provision of services in French, the federal government absolutely must be involved, because it plays a role in this action plan even if health is a provincial matter.”

Cynthia Baker, CASN executive director, agreed, saying CASN considers this to be a national problem related to the provisions of the Canadian Charter of Rights and Freedoms.

The problem, by the numbers

“We are here today to discuss the threat to French-language nursing training outside Quebec and the resulting impact on the care and services offered in French in minority communities,” Baker said.

She highlighted some of the statistics in the Canadian Council of Registered Nurse Regulators (CCRNR) report NCLEX-RN 2016: Canadian Results, which was released to the public two days after the committee meeting.

Overall, 69.7 per cent of the 9,048 exam writers in 2015 passed on their first attempt. After 2,511 of the writers made multiple attempts, the pass rate increased to 84.1 per cent by the end of 2015 and to 92.9 per cent by the end of 2016. Each attempt costs the writer $450.

For the 2016 cohort, 88.9 per cent had passed by the end of the year. That could increase after multiple attempts stretch into 2017.

“The pass rate among anglophones has risen since most schools started purchasing commercial preparatory resources,” Baker told the committee. “Unfortunately, the francophone candidates do not have access to these resources.”

Year-end NCLEX-RN pass rates by cohort*

2015 cohort Writers Pass rate
Writing in 2015 9,048 84.1%
Writing in 2016 1,072 74.6%
By the end of 2016 9,048 92.9%
     First attempt 9,048 69.7%
          French only 138 26.8%
     Second attempt 2,511 65.7%
     Third attempt 603 65.3%
     Additional attempts 109 50.5%
2016 cohort Writers Pass rate
By the end of 2016 9,306 88.9%
     First attempt 9,306 79.9%
          French only 88 36.4%
     Second attempt 1,168 66.2%
     Third attempt 107 57.0%
     Additional attempts 6 50.0%

*Created from data in tables 3, 4, 5 and 9. Canadian Council of Registered Nurse Regulators. (2017). NCLEX‑RN 2016: Canadian Results (p. 10, 11 and 15). Beaverton, Ont.: CCRNR.

The 30-page CCRNR report shows only the first-attempt pass rate for writers of the French exam; the rest covers bilingual Canadian and provincial/territorial statistics. While the pass rate for French exam writers did increase, it went from 26.8 per cent for the 2015 cohort to 36.4 per cent for the 2016 cohort. In comparison, the first-attempt pass rate for English exam writers in the 2016 cohort was 80.3 per cent.

“The last time the Canadian exam was given, the pass rate was about 93 per cent [for the Université de Moncton]; the rate was similar in the years prior,” said Pierre Godbout, director of the school of nursing at Université de Moncton. “In 2015, when the new exam format was introduced, the class had a pass rate of 32 per cent. That was an insult to us, since our students had worked long and hard throughout their bachelor program. In 2016, the results were similar, with a 39 per cent pass rate.” It took two years for the class of 2015 to get an 88 per cent pass rate.

“In New Brunswick, [nursing] programs have to be approved by the Nurses Association of New Brunswick to ensure they meet standards. They must also be approved by the CASN. Our programs, therefore, meet the training requirements of both the provincial body and the national body, so this exam was a huge insult to us,” Godbout said.

Suzie Durocher-Hendriks, assistant professor at the school of nursing at Université de Moncton’s Edmundston campus, said her students have had similar pass rates. “In 2014, 100 per cent of students at our campus passed the entry-into-practice exam. In 2015, the pass rate was 30 per cent, even though the students had taken exactly the same training program.”

Multiple potential causes

Baker said the sources of the problem are the adoption of the American entry-to-practice exam, its translation and the lack of related preparatory material in French.

School of nursing director Sylvie Larocque said the majority of students in Laurentian’s bilingual program wrote the exam in English in 2015, with all students doing so in 2016. “Among the reasons given are the fact that the preparatory resources for the NCLEX-RN exam are available in English only. It has also been pointed out that the translation of the exam is poor.”

NANB executive director Laurie Janes said problems started to arise early in the process to find a new online entry-to-practice exam. “Representing the sole bilingual province, NANB requested that French-language resources be supported during an RFP process for the new exam. When the exam provider was named [the National Council of State Boards of Nursing (NCSBN)], there were no French resources included in the proposed contract.”

In 2015, a student advised NANB that NCSBN published an online English-only resource for students.

“When the draft exam came out, the problem of the lack of French resources was immediately apparent. We raised it,” Durocher-Hendriks said. “We asked where the translations were. We obtained them six months later. At that point, we began to understand that there was a problem.”

Brent Knowles, CNO’s director of analytics and research, assured the committee that an extensive review of NCSBN’s process was completed, including an independent review of the French text that found the content of the exam was accurately translated. However, he said “it’s not the role of the regulator to provide preparatory materials to students in preparing to write the regulatory exams.”

Janes said NANB does not believe the lack of resources nor the translation is the problem with the exam, which has been written in the United States for 20 years. “There is a large number of research articles and documents that inform us that in the U.S., where Spanish is prevalent, the Spanish students have the same experience that our French students are having.” She also said she has heard anecdotal information that Indigenous students are having similar difficulties.

Janes said part of the problem is that French-speaking students need to study language as well as nursing. “For some graduates, this translates into lower academic achievement than is required to succeed in passing NCLEX, and this is the experience faced by non-English-speaking and minority groups in the United States.”

Knowles pointed out that the NCLEX is a different type of exam, a computer-adaptive test. As exam writers answer questions, the system assesses how they performed before generating the next question. No two exams will be the same, with graduates answering 75 to 265 questions until the system determines that the writer has the minimum ability required to safely and effectively practise nursing at the entry level.

“Research indicates that when the format and delivery methods for an exam change, you would expect to see a temporary decrease in the performance of test takers,” Knowles said.

In Ontario, according to a handout he gave the committee, that meant a drop in the pass rate for English exam writers from 85.2 per cent in 2014 to 69.9 per cent in 2015; the pass rate was back up to 80.5 per cent in 2016. However, for those writing the French exam, the pass rate dropped from 65.6 per cent in 2014 to 34.8 per cent in 2015 and reached 37.5 per cent in 2016.

“I feel one of the concerns is that we need to look at this beyond just the factor that a difference in pass rate must mean there’s an issue with the exam. We’re suggesting that there could be other factors at play before we move to stepping away and saying the exam itself is the only issue,” Knowles said. “That’s why we want to actually have some time to take a look at how students are performing, to talk to students and to then speak with our educational partners as well to see what some of the issues are that are at work here.”

Concerns for the future

Whatever the cause of the problems, Larocque said the consequences could have “a major impact on the number of francophone graduates and on the health services offered in French to francophone minorities.”

About a third of New Brunswick’s population of 750,000 is francophone. One health region provides services primarily in English; the other, primarily in French. “Our French health region is the only health system offering all services solely in French outside of Quebec. Many residents served by this health authority speak only the French language,” Janes said. “Our French health region is concerned about a future French-language nursing force.”

“The francophones of northwestern New Brunswick are primarily unilingual and have very limited skills in English. Attending a French-language program and then having to prepare for an exam using resources that are in entirely English runs counter to everything we know about educational methods,” Durocher-Hendriks said. “Our students say they spend as much time trying to understand the English as they do the content of the practical questions. This threatens the French-language health services available to our patients, their families and our communities.”

“Since the NCLEX-RN exam was introduced in 2015, there has been a drop in the number of francophone graduates from the University of Ottawa who have written the exam in French,” said Michelle Lalonde, assistant professor at the school of nursing there. “The pass rate has been below 40 per cent. In 2016, just 15.8 per cent of our students wrote the exam in French, and the pass rate was 39 per cent.”

Laurentian asked this year’s French program graduates whether, if they could go back in time, they would still choose the French-language program: 44 per cent said they would, 28 per cent said no, the other 28 per cent were undecided.

It’s a situation that Baker called a vicious circle. “The poor translation of the exam and the lack of preparatory materials for the French-language exam result in a low pass rate. As a result, fewer francophone nurses are entering the francophone labour market. The reduced number of new francophone nurses offering health-care services in French inevitably impacts health-care services for francophones.”

Knowles reported that the majority of graduates from French programs in Ontario wrote the entry-to-practice exam in French prior to 2015, but the majority have chosen to write it in English since then. “This makes it difficult to get a clear picture of how graduates of French programs perform on the exam,” he said. However, “we saw no difference in the rates of registration or rates of entry to practice for [graduates of English and French programs]. This demonstrates that, in the short term, there has been no impact on the availability of French-speaking nurses to the health-care system in Ontario since the introduction of the NCLEX exam.”

First attempt and year-end (y-e) NCLEX-RN pass rates by province and territory of education and cohort*

2015 Cohort
Province or territory Total writers First attempt 2015 y-e pass rate 2016 y-e pass rate
Alberta 1,637 69.1% 83.9% 93.7%
British Columbia 1,305 79.8% 87.3% 96.6%
Manitoba 490 74.1% 83.1% 92.2%
New Brunswick 322 50.3% 71.4% 88.8%
Newfoundland and Labrador 250 79.2% 92.8% 97.6%
Nova Scotia 393 75.8% 89.1% 97.2%
Northwest Territories and Nunavut 19 84.2% 94.7% 94.7%
Ontario 4,021 67.7% 83.7% 90.9%
Prince Edward Island 62 66.1% 87.1% 91.9%
Saskatchewan 549 60.5% 79.4% 93.6%
National 9,048 69.7% 84.1% 92.9%

2016 Cohort
Province or territory Total writers First attempt 2016 y-e pass rate
Alberta 1,573 78.0% 88.4%
British Columbia 1,497 86.8% 92.8%
Manitoba 466 85.8% 91.6%
New Brunswick 321 60.4% 75.4%
Newfoundland and Labrador 223 87.9% 98.2%
Nova Scotia 382 77.5% 89.0%
Northwest Territories and Nunavut 16 68.8% 87.5%
Ontario 4,216 80.1% 88.5%
Prince Edward Island 66 87.9% 90.9%
Saskatchewan 546 69.2% 84.4%
National 9,306 79.9% 88.9%

*Created from data in tables 7 and 8. Canadian Council of Registered Nurse Regulators. (2017). NCLEX RN 2016: Canadian Results (p. 13-14). Beaverton, Ont.: CCRNR.

Possible solutions
“What you have just told a scandal; it is a huge barrier for francophones outside Quebec who want to study nursing,” committee member and Liberal MP René Arseneault said.

“What I am hearing today is beyond me. I can’t get over it,” committee member and Conservative MP Bernard Généreux said. “One wonders if it isn’t done on purpose in order to avoid having to provide services to francophones in their language throughout Canada, especially health care.”

“Aside from the francophone nurses in Quebec, only four per cent of nurses elsewhere in Canada are francophones,” Godbout said in response. “We aren’t considered numerous enough to justify the creation of commercial material. The market is not big enough.”

Généreux asked whether Quebec’s exam and preparatory materials could be used in the rest of Canada.

The Ordre des infirmières et infirmiers du Québec is a CCRNR member, but it decided not to use the NCLEX, nor did it use the previous entry-to-practice exam.

“The possibility of using the same exam that is used in Quebec was already studied, but since the two health-care systems are very different, a large part of the content would have to be adapted,” Godbout said. “If Quebec were part of the equation, the market would justify the need, given the large number of francophone nurses.”

“We have explored, and explored intensively, the opportunity that Quebec might afford us to partner with them. However, l’Ordre des infirmières et infirmiers du Québec is currently in a transition in their exam. They’re moving to a computer-based exam and are looking at a different blueprint, as it’s called, for their exam,” Janes said. “We felt that they would be a good fit because the exam is offered in English and French and the resources are offered in English and French. However, there are some legislative barriers, and because they’re in transition, they’re not able to assist us at this time. Perhaps there is some opportunity in the future, but not for the next three years.”

“There are no words to express how deeply shocked I was to learn that every provincial professional association, other than Quebec’s, came to an agreement to adopt an American exam that was developed in English,” committee member and Conservative MP Sylvie Boucher said.

Knowles assured the committee that the NCLEX-RN is not an American exam but a nursing regulation exam. “One of those requirements [for the RFP for a new exam] was teaching an exam that would test entry-to-nursing competencies, not cultural differences, because we fully understand that, even in the U.S., there are very specific cultural differences between Florida, California, New York and Michigan.” He added that Canadian francophone and anglophone nurses are part of the process for developing exam questions.

“Talking about the need for moving to a Canadian provider, I think, goes back to understanding what the exam tests. The exam is not a test of the Canadian health-care system. It is a test of nursing competencies, and nursing competencies that are stripped of any cultural differences at all. That’s really the heart of the exam. If we changed the exam, we would still be moving to an exam that would be testing that.”

Whether the exam is Canadian or American was not as much of a focus of the committee as was the rights of francophones outside Quebec.

Committee member and Liberal MP Darrell Samson asked what the federal government could do to help resolve the problem. Durocher‑Hendirks suggested the committee could talk with the governments of New Brunswick, Ontario and other provinces where the French exam is written.

“New Brunswick has been working with a variety of stakeholders, including our government, for the last year and a half now,” Janes said. “We have advised the CCRNR...that because of our situation, we may have to explore — and now are exploring — alternatives to the NCLEX.”

Godbout suggested the committee could enforce the Official Languages Act.

“The CASN members are calling for the development of a Canadian and bilingual entry-to-practice exam,” Baker said, adding that they would work with the professional bodies to provide their expertise in that exam’s development.

Janes made three requests of the committee: recommend and support the immediate availability of French-language study resources from NCSBN, establish a Canadian nursing group to complete a thorough evaluation of the impact of NCLEX for non-English-speaking graduates and other minority groups, and recommend that the result of that evaluation inform the feasibility of CCRNR continuing to use the NCLEX.

Committee members repeatedly asked about the feasibility of going back to the previous bilingual national exam and whether Canada has the technology and know-how to produce a computer-adaptive exam.

“Allow me to paraphrase the prime minister: it’s 2017, after all,” Généreux said. “You say that you wanted to go from a written exam to an online exam. If that is indeed the reason why this exam was adopted...I can’t believe that this is that complicated in 2017.”

The witnesses were not in agreement as to whether the NCLEX issues could be resolved, the previous exam could be reinstated online or a new exam should be created. Regardless, CCRNR’s contract with NCSBN expires in December 2019.

Virginia St-Denis is managing editor, Canadian Nurse.