Registration Examination

Many professions require graduates to write an entry-to-practice exam after completing a degree in their chosen profession. Professions which use an entry-to-practice exam include: medicine; law; engineering; pharmacy; nursing; etc. Other professions also require success on an entry-to-practice exam before giving a graduate a license to practice. The entry-to-practice exam is meant to test graduates to determine if the graduate(s) is competent to practice (medicine, law, nursing) safely.

Health professions maintain a list of required competencies that members must demonstrate through testing. Nursing students are tested during their university program in clinical practice and through other forms of testing. Tests during university studies focus on a large range of required nursing competencies to determine if the nursing student has understood and can apply knowledge for multiple required competencies.

An entry-to-practice exam is focused on only those competencies that are required in the first six to eight months of practice. Exam developers regularly survey new registered nurses, nurse managers, and practising nurses who work with new nursing graduates. The survey asks about the most frequently used and most important competencies that new nursing graduates must have to provide safe, competent nursing care. This information is used to determine how many exam questions will be targeted on any specific area. For example, a nursing entry-to-practice exam may have 40% of questions on pharmacology; 20% on infection prevention; 20% on basic care; and 10% on interpreting test results; etc. The percentage is based directly on what nurses advise the exam developer is most important for safe practice.

While the developer of the NCLEX-RN is based in the United States, it is incorrect to say that it is an American exam.

A prior version of the NCLEX-RN examination existed in the United States for many years. However, that American Exam is distinct and unique from the version of the NCLEX-RN exam that has been administered throughout Canada since January 1, 2015. Prior to the introduction of the NCLEX-RN into Canada, the American exam underwent a comprehensive adaptation and translation process to remove and replace all American content with content appropriate to the Canadian context in both official languages. This adaptation and translation process occurred over a period of several years prior to 2015. It was completed in accordance with internationally-recognized standards and best practice and included review of each and every examination question by boards of Canadian nurse graduates, educators and regulators to ensure that the content was suitable for Canada.

Thus, while the NCLEX-RN exam provider is based in the United States, all examination questions were adapted and reviewed by Canadian nurses before the exam was introduced in Canada. The current version of the NCLEX-RN is the only North American nursing exam that focuses on the most important and frequently used nursing competencies during the first six to eight months of patient care practice.

Although success on the NCLEX-RN continues to improve across New Brunswick, our pass rates of candidates’ first attempts are still lower than other provinces. Other provinces in which nursing schools had low success rates that were comparable to New Brunswick in 2015 have adapted their nursing programs to help improve outcomes. The adaptation strategies are varied and range from changes to admission criteria and progression policies; to integration of new approaches to nursing program delivery; to the participation of nursing faculty in examination development events; to using the bilingual resources available from the examination provider, including a detailed assessment of program strengths and weaknesses related to student cohort performance to help develop strategies for improvement.

While nursing faculty are responsible for the content of nursing programs, the NANB is confident that use of these and other strategies will ensure that examination success rates of New Brunswick graduates will continue to improve.

No. Each and every NCLEX-RN examination question was translated into French by expert translators certified in Canadian French. Furthermore, after each question was translated (and before the questions were released into the database), each and every question was also reviewed by a translation panel comprised of bilingual Canadian nurses who speak French as a first language. The role of the translation panel is to ensure that the quality of translation is appropriate for the Canadian nursing context.

The translation panel was created in 2014. It continues its work today as new examination questions are being continually developed for release into the database. All Canadian nurses with the necessary language competencies can volunteer to participate on the translation panel. Volunteer opportunities can be accessed via the exam developer (National Council of State Boards of Nursing) website. The translation panel meets approximately two times per year in Chicago. All travel expenses are paid by the exam developer.

In addition to the review by the translation panel, independent third party translation reviews of exam questions were completed in 2016 and again in 2018. Both reviews confirm that the translation is satisfactory. Anecdotal reports from faculty within the NB nursing programs also confirm the translation is of high quality.

Persons applying to practice as a registered nurse in New Brunswick must meet several criteria — one criteria is a successful pass on the nursing entry-to-practice exam. Exam results provide a measure of assurance that new nursing graduates should be able to provide required safe, competent care to patients. This practice is in place throughout Canada.

Surveys are sent to registered nurses every three years. In New Brunswick, new graduates receive a temporary license to practice for a limited period. These new nursing graduates are included in the survey. Survey results are then used to make any necessary revisions to the plan for the exam and to assign the number of questions in any specific area.

Nursing graduates who are unsuccessful on the NCLEX-RN examination on their first attempt, nonetheless retain a temporary license for a period of two years, during which time they are able to attempt the NCLEX-RN again. The vast majority of nursing graduates who did not achieve success on the first write have succeeded on subsequent attempts.

As a result, the number of New Brunswick nursing graduates who are unable to enter the workforce due to difficulty with the NCLEX-RN is very low. For example, of the 349 nursing graduates in 2015 –only 5 graduates from New Brunswick nursing programs, have not achieved success on the NCLEX-RN.

No. All necessary study resources are available free of charge in both official languages on the NANB website, including the current test plan, a webinar explaining the computer-adaptive technology, resources regarding how to develop a study plan, sample exam questions, and other material.

The most important resource is the test plan. If a student is not strong in a heavily weighted competency area on the test plan, the student may need to seek assistance from peer tutoring, small group study sessions or ongoing nursing program/faculty support. The NANB interviews all graduate nurses who do not succeed on the NCLEX-RN on their first attempt. These graduate nurses often report that they did not consult the test plan as part of their preparation.

Many companies sell study resources for entry exams of different professions, including nursing. There is no evidence that use of a commercial study guide improves success rates on the entry-to-practice exam. For students who seek a practice exam in identical format to the actual exam, the NCLEX-RN developer has recently introduced the NCLEX Practice Exam, a 125-question bilingual practice exam which is available free of charge on the exam provider’s website.

Countries such as Australia and the UK no longer use nursing entry-to-practice exams. However, in those countries extensive work was completed and changes implemented that have not yet happened in Canada. Some differences include: a) accreditation or review of nursing programs by a multi-disciplinary team of educators, regulators, public representatives and employers; b) nursing regulators have complete authority over nursing education programs; and c) nursing educators and nursing regulators must provide specific indicators of performance to government on a regular schedule.

In Canada accreditation and review of nursing programs is completed by nursing educators only, and university faculty maintain authority regarding the content of nursing programs. At times, this approach can result in a disconnect between what is taught/learned during university and what is required during the beginning of practice as a nurse graduate. An entry-to-practice exam therefore remains in place in all Canadian provinces to help ensure nursing graduates are able to provide safe, competent nursing care.

Beginning in 2012 –NANB worked with the exam provider to identify the most important/recommended resources for exam preparation. All identified resources were translated for service in both NB official languages. Identification of resources continued into 2016 based upon feedback from the NB public, nursing graduates, and education faculty.

Recognizing the need for nursing graduate support, NANB Board and staff-initiated discussion with both NB nursing programs in Fall 2015 and were the first province in Canada to approve opportunities for multiple writes of the exam –while maintaining a two year period of temporary licensure. This practice was intended as a transition policy, which supported NB nursing graduates while allowing time for contributing factors of low Pass rates to be explored. Each graduate nurse who fails the exam initially –is contacted by a NANB nurse consultant to review test results, discuss approaches to developing or adjusting a study plan – and directed to recommended resources (all available on the exam provider and NANB website).

NANB began lobbying in 2015, and continues to lobby the exam provider, other nursing regulatory organizations, the Canadian Nursing Association and NB government departments for exam provider study resources in both official languages. NANB was pleased to review of the November 21 release of the federal standing committee on official languages report, which also recommended resources to assist francophone graduates accessing a greater number of resource materials.

The processes used for a legislated program review vary among Canadian provinces and territories. In New Brunswick, nursing programs are reviewed every five (5) years by a team of expert Canadian educators. Program reports are reviewed by the NANB-Nursing Education Advisory Committee (NEAC) and recommendations from that Committee are then shared with the NANB Board of Directors. In order to reduce the required workload of nursing faculty, NANB tries to align Program Reviews with the university/program accreditation process.

Nursing program accreditation focuses on the quality of the education, while program review focuses on program alignment with nursing education standards and program outcomes. Pending recommendations and discussion at the NEAC and Board meetings, NANB can approve, defer or cancel nursing programs in New Brunswick.

NANB is currently reviewing the processes used for program review. One outcome of analysis of entry-to-practice exam pass was the significant differences between NB nursing programs. It was also noted that both the accreditation and program reviews are peer-reviews, which reduces opportunity for multiple perspectives and feedback for the nursing programs. In countries such as Australia, New Zealand, UK and Ireland, program reviews/accreditations are completed jointly, and review teams are multi-disciplinary and multi-sectoral. Inclusion of reviewers such as employers, interdisciplinary team members (i.e., pharmacy, medicine), public funding bodies, as well as regulators (NANB) strengthens the feedback to programs and contributes to relevancy and currency of review reports.

There are many factors that can contribute to failure on an exam. The NCLEX-RN is a high stakes exam developed for specific nursing competences at the entry to practice level. All graduates need to review the current exam test plan and align that with their own knowledge and skill set. Development of a study plan is necessary.

Other factors which may lead to a failure result include (but are not exclusive): insufficient study time/plan; insufficient capacity (low academic standing/weak clinical skill application); lower literacy levels in either English or French; and personal health issues.

Entrance requirements and progression policies at University of New Brunswick, and at Université de Moncton are significantly different. The criteria for admission can be found on the university program websites. Progression policies determine the point at which students can be placed on academic probation or recommended to transition to a different program of study. Progression policies can also determine when students are required to complete remedial work (including repeating of a course/clinical), and how many courses/clinical sessions can be repeated by a student.

Following early 2015 results, NANB staff reviewed and compared overall results of the entry-to-practice examination for first time writers during the period 2005 –2014. The difference between English and French language writers ranged from 3%-22%. Only one year demonstrated equitable results. In 2014, the year prior to NCLEX -RN implementation, both English and French results were 91% success on the first write.

Results of 85% or higher on the first write of a health professional exam are remarkable, and also required further study. To achieve these outcomes in other health professions such as pharmacy and medicine, students must meet rigorous academic requirements and pass a high stakes entry exam before acceptance into the pharmacy or medicine programs. Students in the programs are also required to maintain the same high academic and clinical performance throughout years of required study.

The Nurses Association of New Brunswick (NANB) has regulatory obligations concerning education standards for nursing programs in the province. In 2019, necessary work to enhance nursing resources will provide opportunity for NANB to augment/ revise nursing education standards that might contribute to outcomes to assure ongoing delivery of safe, competent nursing services into the future.

With the exception of Quebec, all Canadian jurisdictions utilize the NCLEX-RN exam. Quebec cannot use the NCLEX-RN due to legislative restrictions. In addition, beginning in 2019 the basic education for nurses in Quebec will include a specific model of RN-Prescribing. This translates into a different scope of practice for Quebec nurses, and requires a specific entry exam.

The existing national mobility agreement supports standardization in order to promote safe practice by professionals and non-professionals across Canada. While in theory, the amended (2016) mobility agreement contributes to the ability for nurses educated in one province to become registered in a different province, the responsibility of licensing nurses remains completely within each specific jurisdiction. Therefore, provincial organizations responsible for providing nurses’ licenses (registration) can demand licensing requirements that differ between provinces. For example, a nurse educated in NB could be asked to write the Quebec exam before being registered to provide nursing care in that province.

We are not certain. Standardizing entry- to- practice requirements as much as possible enhances the opportunity for nurses to become registered in a different province. This is one of the reasons all nurses in Canada (exception Quebec) have written the same entry-to-practice exam for approximately 40 years.