Perplexed by the NCLEX in Canada


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?


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.

Relationship-building in a Task-Focused World

Increasingly, employees are asked to do more with less.  Arguably, this is the goal of Capitalism: to squeeze out as much work as possible for the least amount of money in order to maximize economic growth. I don’t think that this is a particularly helpful way to approach healthcare, as I believe that it is a basic human right, not a privilege, and that relationships with other people are fundamentally inefficient but extremely important.

In nursing the pressure to perform and maximize efficiency can be particularly difficult to cope with, as increased workloads leave less time to spend with patients and their families which is an important part of our job.  It may not seem like having a conversation is “work” but it is through conversations that patients communicate their needs, hopes, fears, and values (among other things).  By getting to know our patients, we are able to ensure that we provide care that meets their needs and treats each individual holistically, rather than as a list of tasks on our daily to-do list.

Building positive relationships with co-workers and leaders are also essential to creating a positive working environment where nurses and other members of the healthcare team can work together to deliver high-quality patient care.  Investing time and energy into these relationships is not efficient in the short term but pays dividends down the road in terms of staff retention, decreased voluntary absenteeism, decreased short-staffing (which leads to more sick time and burnout, etc.), and of course reduced time spent recruiting, interviewing, and training new hires.  It’s not rocket science that people who like their co-workers and their work environment are more likely to stay than those that dread coming in to work every day.  Strong relationships also facilitate good communication and trust among team members and generate shared understandings of work processes, as well as who knows what, and who to ask when you need help.

While we cannot ignore the tasks that need to be accomplished, as these are obviously important, we need to change how we think about relationships in the workplace.  Culturally, we have a tendency to judge relational work as “non-work” when in fact connecting to others in the workplace is very valuable (and sometimes extremely challenging) work.   Unlike patient care tasks that are easy to quantify and check off, it seems artificial and contrived to make a checklist that says “talked to each of my patients about their concerns”, “invested in my relationship with Susan by asking her about her son’s wedding”…etc.  I would also argue that most of us are naturally social and interested in other people so we do a lot of this work anyway and that trying to maximize relational “efficiency” by reducing these things to tasks is ridiculous (and insulting).

I understand that healthcare is expensive and many of the pushes to increase efficiency are driven by our aging population, aging workforce, government austerity, union wage increases, and the economic recession of 2008 (to name a few things).  It is complicated.  However, we need to invest in people and create healthy workplaces that foster a sustainable workforce and allow our healthcare professionals time to invest in relationships with patients. Pushing people harder and harder to produce more with less is not a long-term solution and will cost us more in the long-run – not just in terms of money, but in quality of life, happiness, and patient care.

Maybe the next time you see a nurse, doctor, or healthcare leader talking with a patient or a colleague, you should acknowledge that they are engaging in valuable work.  Just because we’re not doing a task like inserting an IV or giving a medication doesn’t mean that it’s not important.


International New Graduate Nurse Research Colloquium

On June 20th, 2013, my supervisor, Dr. Heather Laschinger, hosted a wonderful research colloquium with invited researchers from around the world who all have a special interest in gaining a better understanding of the challenges facing new grads during their transition from student to professional nurse.

I feel so fortunate to have been invited!  It was a fantastic day of sharing ideas and research results, as well as thinking about what we can do moving forward to help nurses transition into their new roles.  I also had a chance to share a poster of my recent work about correlates of workplace mistreatment (i.e. incivility and bullying) directed towards new nurses in Ontario.   I wish that kind of research wasn’t needed to begin with but I think a lot of it has to do with structural factors of the work environment (e.g. leadership, workload, resources, support, etc. available to do your job) and personal factors that individuals bring with them to their job.  It is challenging to be kind and happy when you’re working overtime, have a heavy patient load, and are exhausted!    Nurses are valuable health human resources and we definitely have some work to do in supporting them/us and in particular, during transitions to new career roles (new grads or otherwise!).

Overall it was an inspiring day and I am so thankful that so many knowledgeable and fabulous guests were able to attend!    Christine also did a terrific job putting the event together and making the day run seamlessly 🙂  Nicely done everyone!

emily poster 2013

Are nurses too fat?

The most recent issue of Canadian Nurse contains an article about the sad state of nurses’ health but I don’t think it provided the whole picture.  Although I am a nurse, my background is in exercise science and personal training so I have a few things I’d like to add.

1. Most nurses are middle-aged women.  This affects nurses’ health for a few reasons.  Physiologically women have higher body fat percentages than men because of our hormone profile which supports our reproductive role.  Having less muscle mass and high levels of estrogens in our bodies influence our metabolic rate and our body composition.

From a sociocultural perspective, women are still (!) bombarded with messages that they should be thin, rather than fit, making many prone to following fad diets and restricting calories.  This generally results in a “yo-yo dieting” pattern whereby the dieter loses weight while restricting, only to regain it all back, plus a little extra.  Over time, this can make you heavier than you were to start with and make it more difficult to lose weight.  Another thing that people often don’t think about is that the number on the scale does not tell you if you’ve lost fat or muscle. If you lose weight too quickly or are not eating enough calories you are likely losing muscle as well as fat.  As mentioned earlier, this reduces your metabolic rate and doesn’t help you over the long run.  As we age, our metabolism slows down naturally so keeping muscle is a good thing!

As if we don’t have enough on our plate, women generally take on the roles of caregiver, organizer, cleaner, cooker, etc. at home.  So after taking care of patients for 12-hour shifts women often take on their “second shift”, leaving little time for sleeping, let alone physical activity.  And yes, this can apply to men who take on these roles as well but generally speaking our profession is still dominated by women.

2. Most people don’t really understand exercise and nutrition.

Before I knew what a peer-reviewed journal article was, I sought out expert advice about fitness and nutrition from my local library.  While the information from magazines and books isn’t all bad, there is a lot of misinformation out there.  Just because some celebrity follows a certain regime doesn’t mean that it is healthy or appropriate for everyone!

I truly believe that there is no one-size-fits-all approach.  Individuals have different preferences, activity levels, genetics, and budgets to consider.  I am a big advocate of exercise and nutrition as medicine, unfortunately the fitness and nutrition industries are largely unregulated, making it challenging to find professionals who actually know what they are doing.

Which brings me to my next question: how much do most nurses actually know about exercise and nutrition?  Should we be providing advice to patients if we are not experts in this area?  I have mixed feelings about this.  On one hand, as nurses we are often asked to provide general information to our patients and we are readily accessed by the public. Our services are covered under our public health care plan.  On the other hand, we have lots of keen people graduating with degrees in kinesiology and nutrition who ARE experts in these areas but their services are largely available only through the private sector.  Yes, we have physiotherapists and dieticians working in hospitals and clinics, but the opportunities to use them are limited. If you want to hire a personal trainer and invest in healthy food, you are largely on your own.

Really this comes down to the current system’s general focus on disease management rather than preventative health care.  We spend millions on rehab, surgeries, cancer care, etc. and I’m not saying that we don’t need those things too but if we focused more on preventative health care and influencing the social determinants of change that affect people’s everyday lives we could save a lot of suffering and a lot of money down the road.  That applies to nurses too!

We need to create healthy work environments with the structure and culture to support nurses’ health and wellbeing.  Personal choices are also important, but there are real barriers to being able to take good care of yourself when you are a staff nurse working shifts.  Colleagues call in sick so you work short-staffed or work extra-hours to fill in for them – often this results in you becoming run down and getting sick, perpetuating the vicious cycle.  Patients are getting heavier, older, and sicker, adding to the workload we are expected to handle.  There are physiological effects of working nights, not getting enough sleep, and working in a high-stress environment.  To add insult to injury, the less fit we are, the lower our capacity to handle our workloads and the physical and mental strain from working.  Unlike machines, nurses do need time to rest and recover. Unfortunately working out is another stressor added to the mix. Sometimes what your body needs most is sleep.

I hope this doesn’t sound too negative.  There are nurses who manage to take very good care of themselves despite the obstacles.  I am one of them.  I’m not perfect by any means but after a few years of running around trying to be everything to everyone, I have found what works for me.  I have my road bike set up on a trainer in my bedroom and free weights kicking around so I can always do a quick workout at home if I can’t make it to the gym. I make my own food and bring it to work and I eat vegetarian most of the time.  I don’t have cable (but I do watch movies sometimes).  And yes, sometimes I choose sleep or a warm bath over exercise but I feel refreshed and ready to go the next day.  It is about finding balance and for each of us that is going to mean something individual.

Regardless of public perceptions, health is not about being skinny or having a certain BMI (according to which, almost every athlete would be considered overweight or obese!).  Are we role models for health because we are nurses?  Absolutely, whether it is fair or not.  But how is it that we define health?  Are we embracing the unrealistic body image ideals of our culture instead of a holistic view that appreciates multiple dimensions of well being?

While I think that we need to raise awareness of nurses’ health issues through articles such as the one in the current issue of Canadian Nurse, there are a lot of things to consider that were not brought up in the article.  I hope my thoughts contribute to the discussion and I would love to hear what others have to say on this topic!

Have a terrific day!


How to Choose a Supervisor

Choosing your supervisor is one of the most important decisions that you will make as a graduate student.  Personally, I have been very fortunate with regards to supervisors.   I have worked with excellent scholars who have been supportive and kind, yet pushed and challenged me to learn and improve.

As a graduate student, the importance of having a good relationship with your supervisor cannot be under-emphasized.   I started looking for my doctoral supervisor two years before I applied for the PhD program and was fortunate to be able to work with my prospective supervisor as a research assistant during that time.  This gave me direct experience working with her and helped us develop a positive working relationship.  I knew going into my program that she was someone who I wanted to continue working with and vice-versa.  I primarily choose Western because she is an expert in her field and I enjoy working with her.  I lucked out because Western is also an amazing university with one of the best nursing programs in Canada.

I’m not sure that there are any truly bad supervisors out there but I have heard horror stories from friends in other disciplines.  I think it’s also important to consider that two people may be fantastic but have difficulty working together if it’s not the right fit.   If you are in the process of trying to choose a supervisor, here are some suggestions to help you get started.

1. First and foremost, do your research interests align?

You may really like someone but if they are an expert in something that doesn’t really interest you, it is probably best that you don’t work with them.  Investing your time and energy into something that you don’t enjoy is only going to make you miserable and potentially put strain on your relationship.

2. Clarify expectations on both sides. 

What do you expect from your supervisor and what do they expect of you?  Sounds pretty basic but you’d be surprised how many people don’t know what they should expect or look for in a supervisor, or on the flip side are unclear about what they are expected to do as a graduate student.

Start by thinking about what you want to learn through your graduate studies.  What skills and expertise are you aiming to acquire?  Graduate school should be about more than just getting a piece of paper!  This is an exciting opportunity to learn so take advantage of it.  (If you don’t feel this way, perhaps you should reconsider your decision or engage in some personal reflection about your approach to learning).  What do you need from your supervisor to help you be successful in achieving your goals?   Regular meetings?  Constructive feedback?   Opportunities to work on research projects?  High fives?

Ask potential supervisors what they expect of their students.  What GPA do they expect you to maintain?  Which courses do they expect you to take?   How long does it generally take their students to complete their degrees?   What is the expected timeline?   Do they want you to attend certain conferences or work for them as a research assistant?

Being up front about expectations can help you both decide if this will be a mutually beneficial relationship and eliminate a lot of frustration and misunderstanding down the line.

3. Talk to a current or former student.  

Having a coffee with someone who has worked with your prospective supervisor is a great way to get a sense of what they are like to work with.  It can also give you some insight into other aspects of the program such as coursework, other faculty members, and most importantly, its culture.  Is it competitive or cooperative?  Are most students working full-time as nurses, managers, and educators or are they full-time students who spend time together regularly?   Try to get a feel for what the experience has to offer and how that aligns with what you are looking to learn and accomplish as a grad student.

Final Thoughts:

I’m sure there are other questions that you will come up with, but I hope this is helpful in getting the gears going!  I am a strong advocate of nursing graduate education and I think that we need to do a better job of encouraging and supporting nurses who are interested in furthering their knowledge and expertise in this way.   Positive relationships within the academic environment are just as important as those in the health care setting so I encourage you to seek out a supervisor who will offer you their best and who will bring out the best in you.

Have a great day!


STTI Conference Reflections

I just arrived home from the Sigma Theta Tau International (STTI) conference in Indianapolis about creating healthy work environments.  It was a full day of driving there and back from Ontario but well worth the journey!   Everyone I met was so positive and inspiring – I wish we could spread this positive energy to the four corners of the earth and remind our colleagues that healthy workplaces are possible.  Are there barriers?  For sure.  But without a vision and passion for change, we are going to stay where we are, which unfortunately isn’t always  ideal.

Some of the highlights of the conference for me were listening to the panel discussion that kickstarted the conference on Friday morning, hearing Dr. Cindy Clarke speak later that day, and having a discussion about some of the challenges of having an academic career in nursing.

I had a real “light bulb” moment on Saturday when we were discussing the importance of recruiting and retaining doctoral-prepared nurses in academic positions and the value of  staying current in our clinical practice in addition to balancing the demands of teaching, research, and service while pursing tenure.

It dawned on me that the academy was not built with practice disciplines in mind, therefore clinical practice is not valued at many institutions in the same way as the traditional tripod of responsibilities (i.e. teaching, research, and service).   How can we be expected to prepare undergraduate students to become professional nurses if we are not up to date on our nursing skills and current best practices?  On the other hand, how can we possibly become and remain experts in all domains and still have a life?!    I’ll be the first to admit that I work 50-60 hours/week on research and schoolwork and the remainder of my time is spent with my son, working out, squeezing in other activities (like writing and grocery shopping) and sleeping.

Although I love my job as a staff nurse I am dreading going back to work in September when my maternity leave ends.   I know from experience that spreading yourself too thin takes a toll on my body and my mental health.  Not to mention that when quantity of activities increases past a manageable level, quality often suffers.   Having to choose between spending time with my son (which I will never get back) and running around like a crazy person trying to build my CV and establish my career is not easy.   I care deeply about nursing and I want to contribute to our profession in a meaningful way.  I also love my son and cherish all the time we have together.

Women already face enough challenges pursuing academic careers without the added obstacles of pursing one in nursing.  How can we expect nurses to give up their high-paying (and often unionized) staff nursing jobs to go back to school and still support their families?  Moreover, how can we expect nurses to complete their doctoral work while teaching or working full-time and often working the second shift at home as a mom and house manager?   Yet, so many do.   If we are going to successfully recruit and retain nursing faculty, we need to be more supportive of talented nurses who want to become educators and researchers.  We need to recognize and appreciate that as individuals we cannot and need not be experts in everything.  Every nurse has different gifts and strengths to offer that bring a wealth of knowledge and ways of being that enrich our profession.

For me, valuing, respecting, and embracing diversity is fundamental to creating a healthy profession and a healthy work environment.  Just because I have a passion for research and teaching and a few extra letters next to my name doesn’t mean I don’t admire and value the experience and expertise of seasoned staff nurses.  It would be completely ignorant of me to think that I know more or better than others; I simply know differently.  I would be gravely mistaken if I thought that what others have to offer makes me “less than”.  I can only hope that my colleagues in practice embrace the same attitude: I might be pursing an academic career but I am still a “real” nurse.

Thankfully, my nurse colleagues in academia have been so supportive and encouraging!   I have so much to learn and a long way to go but I am inspired by the courage, wisdom, and strength of the nurses who have led the way before me.   I am so fortunate to be surrounded by such wonderful scholars and nursing leaders.   Together we are all going to accomplish so much!