Tag: nursing education

Perplexed by the NCLEX in Canada

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To most Canadian nursing educators, the NCLEX is about as welcome in Canada as Donald Trump. I am not alone in being royally PO’d that the provincial nursing regulatory bodies decided to nix the Canadian Registered Nurses’ Exam (commonly known as the CRNE)to replace it with the NCLEX in 2015.

In case you’re not in nursing or you aren’t Canadian, the NCLEX is the American nursing licensing exam that all American nurses must pass after their nursing degree before they can register as a Registered Nurse.  It is an adaptive computerized test that will keep asking tailored questions until the program is 95% sure that the candidate is above or below the passing standard.  To be clear, I think that this format and system of testing is awesome.  What isn’t awesome is having to teach my students content that is American so that they can pass the test (as if we don’t already have enough content!).  The French translation of the NCLEX is also so bad that many Francophone students are failing because they can’t understand the questions (I’m talking outside of Quebec of course because they wisely decided to keep their own nursing exam). Moreover, although French NCLEX practice materials are starting to pop up (after they realized that it was an issue), there aren’t nearly as many resources for French students and educators as for their English-speaking counterparts.  Two giant strikes for the NCLEX.

I have no idea why on earth the provincial nursing regulatory bodies made this decision or if they understood the implications of their decision.  Initially I was told that it would be a Canadian version of the NCLEX and maybe they thought so too. It is not. It is the exact same database of questions for all candidates in all countries. I could be wrong but I think the rationale behind this is that the NCLEX supposedly is “context-free”. I attended an NCLEX workshop for nursing faculty two years ago and the facilitator explained to us how the test worked and how the questions are designed.  She also proudly stated that “the NCLEX has no context”.  What she meant was that the questions are designed to be applicable to all contexts. I would question that. Is nursing really that black and white?  Maybe some things are but I’d argue that real life requires professional judgement calls too.

There are also huge differences between the US and Canada in terms of how we view health care (as a service to be bought through insurance versus as a basic human right).  Specific examples of the “Americaness” of the exam include “the five rights of delegation” and the scope of practice for an RN versus and LPN (Licensed Practical Nurse)[or RPN (Registered Practical Nurse) in Ontario]. In Ontario where I started my nursing career, I worked on a hospital unit with half RNs and half RPNs. We both had our own patient assignments and although the RNs were able to be in charge and dealt with the more complex patients, we were never assigned an RPN to delegate work to and have them report back to us. They had autonomy and we all worked together as a team (for the most part). In the US, LPNs report directly to RNs and the RN assigns patients or patient care duties to them. LPNs are not allowed to engage in patient teaching or any of the nursing process (assessment, planning, evaluation, nursing judgment). (See the Joint Statement of the American Nurses Association and the National Council of State Boards of Nursing here). Why does this even matter? Well, now we have to teach our nursing students about delegation in their own province and the rest of Canada (it is not exactly the same from province to province) AND America. If we don’t tell them that delegation rules for the NCLEX they are going to answer those questions incorrectly and it sure as heck isn’t because we don’t teach them about delegation in Canada.

Some have argued that it is not an American test, to which I respond, then why are Canadian-specific NCLEX prep books popping up?  Is it because we are just another market that companies want to exploit, or is it because there is American content that Canadian students need to learn in order to do well on the test?

So where does this put us?  Precisely in a giant head-lock. We have excellent nursing programs across Canada and in general our nurses have more education and better quality education than nurses in the US. Many of their students still take 2-year associate degrees whereas in Canada all RNs have to have a four-year bachelor’s degree. Every day I am impressed with the quality of the education that the students get at UNB and especially with the amount of real life clinical they get (over 1400 hours).  However, now we need to add in NCLEX-specific content to make sure that our students are prepared to take an American nursing test. Not to prepare them for their practice as an RN – we do that exceptionally well already!

Clearly I have strong feelings about the NCLEX and not everyone will agree with me but I don’t think that Canadian nursing students should have to learn American content in order to become nurses in Canada. I also don’t think that nursing schools should be judged by their NCLEX pass rates. Passing the NCLEX or not doesn’t necessarily reflect the quality of a nursing program, but, rather the “NCLEX test readiness” of graduates. Some schools are starting to make it a requirement for nursing students to write the HESI NCLEX practice test and obtain a certain score before they can graduate and write the NCLEX. This ensures that pass rates on the actual NCLEX are high because it increases candidates’ test-taking skills and ensures that they don’t write until they are ready (sometimes after writing the HESI numerous times).  As a result, high NCLEX pass rates are not necessarily a reflection of the quality of the nursing school, but of the readiness of the student to write the NCLEX. I don’t think that it is a bad thing to take the HESI per se, but I do think it is misleading to compare first-time NCLEX pass rates between schools who have a HESI score requirement and those who do not. Taking these tests (the HESI and the NCLEX), attending NCLEX review sessions, and purchasing NCLEX study guides are also very expensive so making the decision to require the HESI is not one to take lightly.

So there you have it. The NCLEX has made it harder to become a nurse in Canada and more challenging to be a Canadian nursing educator. Arguably, it has also made it easier for Canadian nurses to practice in the US (if you don’t mind working in a f0r-profit health care system). I’m not a fan and I think that it was strange decision. It is also possible that I am not privy to confidential information about why this decision was made and, thus, do not fully understand the rationale behind it. That being said, until the situation changes, it really doesn’t matter if I agree or not, no matter how logical my arguments are; the fact is that we need to do what we can to prepare our students for an American test.

 

 

So you want to be a Nurse Practitioner?

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First let me say that Nurse Practitioners (NPs) play a valuable role in our health care system.  As nurses with clinical expertise from years of experience working with patients and advanced educational training, NPs have a lot to offer patients, healthcare teams, and organizations.  NPs are awesome and job opportunities for nurses in this role are increasing, in part because they are a more cost-effective healthcare resource than general physicians.

However, in talking to nursing students, reviewing scholarship applications, and entering survey data from new graduate nurses, I have noticed that everyone and their dog seems to want to be an NP.  I have also fielded lots of questions from people about how to get into the NP program, mainly “what GPA do I need?” and “what’s the minimum amount of experience I need before I apply?”   Another thing that I have noticed is that many people who did not choose nursing as their first career choice wanted to be doctors which makes me wonder if some people see nursing only as a means to become an NP, under the misconception that NPs and doctors are pretty much the same thing.  Let’s unpack this a little bit.

1. We need more NPs but we need way more nurses.  I hate to bust your bubble but from a resource planning perspective we need way more RNs in the workforce than NPs.  It’s actually more competitive to get into nursing and Canadian NP programs than medical schools. To boot, in Ontario you are only allowed to apply to one program per year so if you don’t get in (which is highly probable), better luck next year.

2. If you don’t want to be a nurse, do something else.  This may seem ironic coming from someone who’s career goal is to becoming a nursing professor but I wholeheartedly love being a geriatric rehab nurse and if I didn’t care so much about the bigger picture I would be happy to work full-time as a staff nurse.  I believe that most nurses who become NPs really want to make a difference in that role and I admire that.  However, I think that one of the things that makes the NP role so valuable is the wealth of nursing experience that people bring with them.  You can’t skip that part and if you don’t like getting your hands dirty working in the trenches, perhaps you should reconsider your career choice.   After all, chances are pretty good that you will work as an RN rather than an NP for most of your career.  There are also tons of other people who would love to be a nurse and you are taking their spot.  I’d also like to point out that if you wanted to be a doctor and end up working as a staff nurse you might end up really hating your job and being resentful.  Maybe not the best life choice.

3. 2 years of experience is not enough for most people and who cares about your GPA, really.  Some of my research work is on new graduate nurses and we consider a new graduate nurse anyone with less than 2 years of nursing experience (and sometimes even 3 years or less).  Patricia Benner also outlines the stages of development from beginner to expert nurse, stating that it takes about 3 years to become competent and at least 5 to become an expert.  Given that we know that it takes several years to develop nursing expertise, it baffles me that nursing schools allow nurses with a minimum of 2 years of clinical practice to apply to their NP preparatory master’s programs.  Moreover, it concerns me that some people are in such a rush to become NPs without considering the amount of responsibility that comes with their new role and the benefits of having more experience (to their patients as well as themselves).  There are exceptions I’m sure but I really think we need to reconsider the minimum experience requirements, especially considering that there is high demand for NP education.

While I’m on the topic of NP education, I don’t think GPA is necessarily a good indicator of an excellent nurse or of someone who will make a fantastic NP.  That isn’t to say that you can’t have a high GPA and also be an awesome clinician.  My point is that there are amazing nurses who are highly knowledgeable and skilled, with high levels of emotional intelligence and leadership skills that may not have achieved a 4.0 in their undergraduate nursing program.  I don’t think we need to throw the baby out with the bathwater here because the NP program is demanding and rigorous but it would be nice to see other elements included in the application process.  In real life it doesn’t matter what your GPA was if you have limited social skills or can’t apply the knowledge that you learned in a meaningful way.

Before you jump on the “I want to be a Nurse Practitioner” bandwagon, I hope that you will take some time to engage in self-reflection about where you are in your career and what skills, knowledge, and experience you have to offer, as well as areas that you want to develop further.  Just because you have a perfect GPA and can apply to an NP masters program after 2 years of working  doesn’t mean you should. Not everyone is cut out to be an NP and being an RN can be as rich and rewarding a career as you want it to be.