Nursing students and schools are sounding the alarm on what they see as an "Americanization" of Canadian university nursing curriculum. Some say an American-style exam could end up sending more nurses south of the border.
Their concerns surround the NCLEX-RN, the exam all nursing graduates must pass before beginning to practise.
In 2015, nursing regulators across Canada began using the NCLEX, a test developed and used in the United States, with some Canadian adaptations.
The test is not part of the university curriculum and is administered after graduation. It is computer-based, and was believed to be more secure than the old Canadian entry-to-practice nursing exam, which was written with pen and paper.
No link between GPA, exam success
But the director of Dalhousie University's nursing school said the test isn't necessarily a useful tool.
"We don't see, in some of the evaluations we've been doing here at Dalhousie, a relationship between a student's grade point average and success on the NCLEX-RN," Kathleen MacMillan said Monday.
MacMillan said the school has also found no link between the NCLEX and a student nurse's competence in a clinic or hospital.
That has some student nurses asking why they are taking the test at all, and how well it reflects what they're learning in school.
Burnt out before beginning
"What we've been told is that it's supposed to be Canadianized," said Dylan Naugler, a fourth-year Dalhousie University nursing student who studies in Yarmouth.
"From what we've heard from previous writers from last year and the year before, is that there are still some discrepancies as to it reflecting our values."
In early 2015, the pass rate for students on the first attempt at the NCLEX was 80.7 per cent. The pass rate for the previous Canadian exam was about 92 per cent. The pass rate has been improving since then.
Naugler said Dalhousie has significantly stepped up training and testing in the last few months, and even so, students who do well in course work are not always able to pass the practice exams meant to simulate the NCLEX.
"We're being burnt out before we enter the profession, and that's a huge concern," he said.
Test ignores Canadian techniques
The test is a series of multiple choice questions that adapt as the test progresses. Students cannot return to a previous question if they want to change an answer.
On Friday, the Canadian Nursing Students Association called out the test for having problems, including a poor French translation, which it said caused a 27.1 per cent pass rate for Francophone writers.
The association is concerned students are being forced to spend more time on NCLEX prep materials, which takes time away from clinical time and the regular curriculum. There are also few preparation materials for the NCLEX in French.
The association says the test ignores concepts taught in Canada such as community-based nursing, Indigenous health and public health.
Letter writing campaign and petition
"Up here, we're very holistic in our thinking," said Bryce Boynton, association president.
"It's actually assessing the whole Canadian, the whole family, the whole community. Down there, they're very single-person focused, very task focused."
Boynton said the association has organized a letter writing campaign and petition about the NCLEX, with hundreds of nursing students signing on.
The association wants the test to be changed to better address Canadian content and context, and serve the needs of Francophone nursing students.
Lured to the United States?
MacMillan supports the association's call for change on the NCLEX. She said she'd like to see a third-party evaluation of the effects of the NCLEX in Nova Scotia. She worries adopting a national U.S. test makes it too easy for Canada to become a source for American nurses.
"What this does, essentially, is it colonizes Canadian nursing to a dominant culture, where health care is a business model and ours is based on people's human rights for access to care," she said.
She said the school of nursing and students are already paying higher costs for test prep material.
"One year, I spent $50,000 on exam prep materials out of my budget," she said. MacMillan said her staff are spending more time on preparing students for the NCLEX, and that staff time equals the work of one full-time faculty member.
"So that's one less professor that I have to actually teach," she said.
Nurses' union weighs in
MacMillan said although most Canadian nurses do not choose to go south, the U.S. is facing a nursing shortage and could look to Canada to fill the gap.
The president of the Nova Scotia Nurses' Union, Janet Hazelton, said she worries jurisdictions in the U.S. might be able to get personal contact information from the NCLEX to contact Canadian nursing school grads and offer them positions with higher pay.
"These new grads, with bills, can be lured to sunny Florida quite easily. And we can't make it any easier," she said.