Nurses Continue to Express Concern over CRNE Decision, by Betty Poag RN

I have a number of concerns about the decision made by 10 of Canada's nursing regulatory bodies to select an American organization, the National Council of State Boards of Nursing, to develop a new examination for entry-to-practice which will replace the current Canadian exam by 2015 . I used the letter on the Canadian Nurses Association (CNA) site to register my concerns with local members of the legislative assembly, the College of Registered Nurses of BC (CRNBC) and others. Laurel Brunke at CRNBC responded to my letter. I thought about all the concerns I would like addressed and drafted a letter that my colleagues felt expressed their own feelings of dismay and concern. I have included it here below. I am a proud Canadian and having worked internationally, I am proud of the respect that Canadian nurses, I believe deservedly, garner. I do not wish this reputation to be compromised in any way and I believe that this plan could well have that effect. In response to the points Ms. Brunke made, we responded…

Meeting Canadian Requirements:

Participating in oversight of exam development is not the same as developing it with an extensive and nuanced understanding and experience of the unique Canadian health system. I have worked in the U.S. myself and in other jurisdictions internationally. The U.S. health systems are very, very different in my experience.

I am interested in what EVIDENCE in the literature you are using to base the decision to have a U.S. company design and develop a Canadian exam for Canadian nurses practicing in a Canadian health system? I am curious about how the “input” of Canadian nurses, educators & regulators will be measured and at what level this input will be provided? How will accountability be assessed as time goes on and the contract with this company is firmly established? Will nurses, regulators and nurse educators apply to participate on this committee? Will nurses in Canada be informed about the process and to what extent will they be informed? How many years will Canadian nurses, regulators and nurse educators be providing input? Will it only be after the first cohort is examined, will it be in the first five years and will the same level of input be sustained over the time of the contract with NCSBN? What tool will be used to measure and describe, for Canadian nurses, whether the input is meaningful or a token attempt to include Canadian input into an essentially U.S. exam.

Computer-adaptive exam:

While I personally would have no desire to write a computer based examination, that is somewhat less concerning to me than the practicalities.

Who will fund the implementation of this method of examination at all of the Schools of Nursing across our Canadian Provinces and Territories? From the perspective of an educator, I sincerely hope that the Canadian RN regulators do not expect that, at the end of nursing education and training, nurses will suddenly be faced with a “state of the art computer adaptive RN entry exam” having never before used or worked with this technology in any of their education or previous exams.

As a nurse, who has seen in B.C. the decimation of funding across many sectors, to expect Colleges and Universities to magically come up with funding to implement this technology into their programs is unrealistic and irresponsible. Using new & unfamiliar technology to write the most important exam of your career would pose a significant challenge for the student writing a “Canadianized US exam”.

Entry to practice competencies:

I recognize the entry to practice competencies are critical to ensuring safe, ethical, competent and accountable nurses and nurse colleagues in my workplace. I also recognize the practice exam is one of the important tools to ensure that these are the nurses I will be working with in the future.

However, I am not sure that using a US company to assess this is the only option to ensuring these are the nurses who graduate. I am working right now with an incredible student nurse who has been educated at a Canadian university, practiced across several sites and health practice areas, is currently working as an employed student nurse and will write an exam developed right here in Canada. She is absolutely competent to practice and she is the nurse I want to practice with in the future. We already have entry to practice examinations that accurately reflect practice. If not, we have a bigger problem in our hospitals and communities than this exam will address and how did all these nurses pass an exam and be let loose on the unwitting public as incompetent and not safe to practice?

Having a secure exam:

It is my understanding that a majority of US companies fall under the Patriot Act. This means that there is no such thing as “private information”: the US government can access any personal data it wishes on any Canadian nurse writing exams. Presumably, this means social insurance numbers, birth dates, contact information and any other information that is required to allow a nurse to register, write and send and receive any information examiners require. Accessing our private information is done at the will of the U.S. Government and not with the consent of the College nor does the U.S. company have any choice in the matter.

In addition, high profile companies and government agencies have been “hacked”, so in spite of “world class security and data protection”, there is no guarantee. Whatever the efforts of the College, the reality is that we are a Canadian group of professionals whose personal and private information will be available to U.S. government under the Patriot Act. The College can do nothing about US legislation.

If there were questions or concerns about the Canadian RN Exams assessing entry to practice, why were Canadian nurses not made aware of or asked about the subject and feedback sought?

How much will this cost and who is going to pay? Is the provincial or federal government? Highly doubtful. Will the money come from my College of Nursing fees? Will my fees rise to cover the cost of the NCSBN developing and delivering the exams to Canadian Nurses as well as the technology platform required to be in place to test nurses?

Is there no single Canadian company across this nation that has the capacity to develop and deliver this product in Canada where Canadians may be employed? We keep hearing about unemployment and the economy, are we now going to employ U.S. citizens to facilitate the development and delivery of this exam for Canadian nurses?

I am extremely frustrated and disappointed by this decision and the abrupt announcement with no discussion or preparation makes me suspicious that this was a political decision rather than a well-researched, well thought out, consultative decision.

I continue to be very concerned and I wonder what Canadians will lose next, our health system?

The views and opinions expressed in this post do not necessarily reflect the views and opinions of the ARNBC.


Betty Poag has worked as a staff nurse and clinical educator in the perinatal setting for over 27 years. She developed an interest in Women’s Health following her participation in a provincial Women’s Health consultation in 1995. She worked as the nurse coordinator of the BC Women’s Woman Abuse Response Program for five years, providing education to health and community agencies throughout BC about the complex issue of violence and abuse in relationships. At the request of Healthy Child Manitoba, Betty and her colleague Lynda Dechief provided Violence and Trauma Informed FASD Prevention workshops to over one hundred workshop participants from across several health, social, justice sectors from communities across the province of Manitoba. For the past four years Betty has led the planning and development of the HerWay Home Program in Victoria which will provide services to pregnant or early parenting women struggling with substance use, and/or experiences of violence/abuse, and/or mental health challenges. Betty is currently working as a Public Health Nurse.

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Julie C

Betty, thank you for sharing this. I am a student and I was noticing that there is less talk about this on Twitter than there was even a week ago. I was wondering if there were updates about what is going to happen? Did the people who wrote letters and lobbied to have some say in this have an impact? Can the decision be reversed? What will happen now? I thought maybe because there isn't so much talk about it now that the CNA were giving up.

Betty Poag

Hi Julie,

No, CNA is not giving up. They have a petition on their website that you and your classmates and others can sign. In our most recent Canadian Nursing Journal, postcards to Canada's Minsiter of Health were inserted urging Minister Aglukkaqq to intervene.

The student I am working with has started a Facebook Page and has had a huge number of nurses and non-nurses sign on to support the pushback against this decision. Nurses are talking to one another.

I am not sure of the impact we have had to date, but I plan to continue to seek answers to my questions.

I think that it is very interesting that while I received a response, from Laurel Brunke at CRNBC, to the CNA generated letter that I signed and that went to several MLAs as well as CRNBC, I have not heard back regarding the above letter.

I think nursing must think carefully about the long term implications of this decision and I urge you to share the link to the discussion here and at CNA with family, friends and colleagues. It is so important to keep this topic on the minds of nurses and to keep talking about and raising it. If nurses don't raise their voices, this will happen and once it does, there is no going back.

Thanks again for your interest Julie.