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CNA certification goes international
Sep 01, 2017, By: Rose Simpson
The invigilator team group picture
The invigilator team for the certification exam administration in Dubai in December 2016.

A two-year pilot project to bring the CNA Certification Program to the United Arab Emirates (UAE) is attracting worldwide interest and has led to the development of an online module to help emergency nurses in Canada and abroad prepare for their exams.

The project was part of a partnership between the Dubai Health Authority (DHA) and the association to apply Canadian nursing specialty standards in another country. CNA has been in the certification business for 26 years but had never before offered this program outside Canada.

A total of 420 emergency, nephrology and adult critical care nurses in Dubai wrote specialty exams between 2014 and 2016. Of this group, 156 became certified.

The idea for the project came from Roxanne Nematollahi, an Iranian-born Canadian nurse and academic who is the DHA career development specialist in nursing and midwifery. After immigrating to Canada, Nematollahi received her certification in oncology nursing in 1997.

“When I came to Canada, I had years of experience working in oncology, but I was very limited because I wasn’t certified,” she says. “After I moved to Dubai, I saw that my nurses were in the same boat. Nobody recognized them as specialized. That piece of paper, no matter how much experience and how much knowledge you have, is really important.”

Nematollahi asked CNA to bring the Canadian certification exam to Dubai and to connect her with expert nurse educators in emergency nursing.

A global contribution

Her request was met with enthusiasm by CNA, whose leadership saw the Dubai project as a way to test out recent improvements to its certification program.

“There had been two operational reviews, conducted in the past five years, and both called for changes to the program,” says Patricia Elliott-Miller, CNA’s executive lead for Certification and Professional Development. “It was felt that the program should explore other opportunities for growth and be flexible to meet the needs of those who requested it.”

Global expansion of the program was also a way for CNA to make an important contribution toward improving health outcomes.

Gordon Boal, a former KPMG partner, was asked to lead the project because of his extensive international experience. Boal worked with Nematollahi and 15 DHA subject matter experts to tailor the exams for the reality of Dubai.

The challenge was to have an international exam for each of the three specialty areas, based on the CNA exam blueprints, that would meet Canadian standards while addressing the cultural and practice sensitivities of nurses working in another country.

“We looked at every question and every answer on the Canadian exams to see if there was anything that could be conflicting, compromising or misunderstood because of the issues of culture, language, units of measures and nursing practice,” says Boal. “We ended up modifying the exams within accepted psychometric principles — ensuring reliability, validity and defensibility.”

There were a few questions, including those about palliative care, that were deemed culturally inappropriate.

“Palliative care is not officially in full practice within our hospitals,” Nematollahi explains. “There were questions about advance directives on the Canadian exam and about DNR orders, which is considered an ethical dilemma and is not currently approved by the regulatory body. Our nurses don’t have a clear understanding and direction about this, and it is considered a challenge in the decision-making.”

Another key difference between the Canadian and international exams related to the qualifications of the nurses. In Canada, eligibility to write the exam is determined by CNA. In Dubai, the DHA determined eligibility.

During the process of the emergency nursing exam review, Boal facilitated discussions to provide examination support to the DHA nurses writing that exam. Canada’s National Emergency Nurses Association (NENA) identified members to develop and deliver a two-day workshop.

One of those members is Margaret Dymond, who has been a clinical nurse educator at the University of Alberta/Stollery Children’s Hospital for 22 years. She is also the director of training and education for NENA.

“The first session [of the two-day workshop] was a mass of people,” she remembers. “We asked people to raise their hands if they’d done certain courses. The ones who didn’t raise their hands knew they’d have to do extra prep to take the exam.”

After that session, the DHA decided to scale back the number of workshop attendees and asked for a more interactive approach.

Dymond says the second approach was more effective.

“Once the nurses learned to trust us, and realized we weren’t judging them, they were more engaged. And one of the biggest gains was having their nurse educators in the classroom. They saw how they might be able to do [these sessions] on their own.”

Nematollahi says she has noticed a big difference in those nurses who attained certification.

“They feel such pride,” she says. “They feel more respected, especially by the physicians.”

While the Dubai pilot was deemed a success, it has been put on hold to allow DHA’s new leadership to decide how best to move forward.

However, because CNA was able to specifically tailor its program to Dubai’s needs and cultural and practice sensitivities, the association has signed a contract with a health-care facility in Abu Dhabi, UAE. Nearly 75 nurses from three specialties — gastroenterology, perianesthesia and critical care — will write certification exams in December.

Other countries are also showing interest.

Bringing the benefits home

The project has benefited Canadian nurses as well. After the first session in Dubai, Dymond realized there was a gap that could be filled by an online module to help prepare emergency nursing exam writers.

“I had put so much into developing the content for these sessions, that I didn’t want it to be a one‑time‑only thing,” she explains. “So I changed my PowerPoint into a question-and-answer format that included scenarios and found an online platform that could be accessible to any nurse with any electronic device.”

The online module, which went live in fall 2016, is free of charge for nurses worldwide who are preparing for the emergency certification exam. Dymond is now working with a certification committee at NENA as it looks at the content to make it even more valuable for emergency nurses.

“What Margaret did was expand on what she learned from her experiences in Dubai to benefit nurses at home,” says Elliott-Miller.

Dymond’s sense of satisfaction comes from knowing that she is making a difference by giving nurses a new tool to help them get certified. So far, it is in use in 13 countries.

To access the online module, visit

Rose Simpson is a freelance journalist in Ottawa.