A new era on the horizon - challenges and implications of the NCLEX-RN exam in Canada

International Journal of Nursing and Health Science 2014; 1(6): 46-54 Published online November 30, 2014 (http://www.openscienceonline.com/journal/ijnhs) A new era on the horizon - challenges and implications of the NCLEX-RN exam in Canada Anousone Rowshan, Mina Singh York University, Faculty of Health, School of Nursing, Toronto, Canada Email address anousone@yorku.ca (A. Rowshan), minsingh@yorku.ca (M. Singh) To cite this article Anousone Rowshan, Mina Singh. A New Era on the Horizon - Challenges and Implications of the NCLEX-RN Exam in Canada. International Journal of Nursing and Health Science. Vol. 1, No. 6, 2014, pp. 46-54. Abstract The decision by the Canadian Council of Registered Nurse Regulators (CCRNR) to adopt the American-based NCLEX-RN exam as the new national licensing/registration exam in Canada beginning in January 2015 has wide ranging effects on nursing students, graduates, educators and faculty as they must understand how to successfully prepare for this new exam. This study examines the reasons for adopting the NCLEX-RN as the new licensing exam, how the NCLEX-RN is developed and the use of a computerized adaptive test to administer it. The results of Practice Analyses studies by NCSBN serves as the basis of the NCLEX-RN test plan. As a computerized adaptive test, the NCLEX-RN is psychometrically sound and can be legally defended. Implications for Canadian stakeholders include understanding testing anxiety among nursing students and graduates, the psychological domains measured by the NCLEX-RN, the new test content, and the new computer adaptive test delivery. Research completed by our American neighbors who have twenty years of experience in preparing their students for this computerized adaptive test offers insights for Canadian stakeholders as they face this challenge. Keywords NCLEX-RN Canada, Canadian NCLEX-RN, Canada Nursing Licensing 1. Introduction The year 2015 marks a new era in Canadian nursing. For the first time, the American national licensing exam, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) replaces the Canadian Registered Nurse Examination (CRNE) as the national licensure/registration examination in Canada. Although this is not the first time an American exam has been used as a national nursing exam in Canada, it is the first time that the NCLEX-RN is being implemented (History, 2014). This is a monumental change as the CRNE has been the national exam since 1970 (History, 2014). The CRNE is Canadian owned and developed by the Canadian Nurses Association (CNA) and its testing company, Assessment Strategies Inc. (ASI) (History, 2014). According to the Canadian Council of Registered Nurse Regulators (CCRNR), the last writing of the CRNE will occur in October of 2014 (Canadian Registered Nurse Examination (CRNE), 2014). Beginning in January 2015, the NCLEX-RN becomes the new national licensing/registration examination for nursing school graduates in 10 Canadian jurisdictions (NCLEX-RN Exam News, 2014). The NCLEX-RN exam will not be offered by the Yukon Registered Nurses Association and L Ordre des infirmières et infirmiers du Québec in 2015 (History, 2014). This change in the national licensing/registration exam poses a number of challenges to the Canadian nursing scene. There are concerns over the loss of Canadian content to adequately preparing students for successfully passing the exam. The key for Canadian nursing students to successfully pass the NCLEX-RN exam lies in understanding what this exam entails and the challenges it poses to both nursing students and nurse educators alike. This paper will provide a background into the NCLEX-RN selection as the new national licensing/registration exam, and its implementation, including a review of the exam development, content, administration and passing grade. Furthermore, it will discuss

International Journal of Nursing and Health Science 2014; 1(6): 46-54 47 potential advantages of the NCLEX-RN exam and focus on the challenges presented to nursing students and educators. Finally, implications for nursing education and research are discussed. 2. Background 2.1. Selection of NCLEX-RN Exam Nursing regulators such as the College of Nurses of Ontario (CNO) are tasked with ensuring that new nurse graduates have the necessary knowledge, skills and judgment to practice safely and ethically in an entry level position upon graduation. In a Webinar broadcasted in December 2012 which was co-hosted by the Canadian Council of Registered Nurse Regulators (CCRNR) and the National Council of State Board of Nurses (NCSBN), Anne Coghlan, Executive Director/CEO of CNO and President of CCRNR outlined the reasons for partnering with NCSBN to utilize the NCLEX- RN exam as the new registration/licensure examination (CCRNR - NCLEX Education, 2012). She outlined the challenges that regulators face as nursing is an evolving profession where there are changes to the scope of practice and advances in technological tools to support nursing practice. Furthermore, the government has challenged regulators to ensure timely access of graduates to the profession in order to facilitate labour mobility. Anne Coghlan also stated that with nursing students today being "technologically astute", they would embrace a computerbased test (CCRNR - NCLEX Education, 2012). In fact, she stated that students have asked for a computer-based test over the past decade. With these considerations in mind and with the focus on public safety, the NCLEX-RN exam offers a computerized adaptive test that is secure, psychometrically sound and legally defensible that is accessible all year round. Anne Coghlan also stated that the exam is evidenced-based and fair as it provides an equal opportunity for nursing graduates to demonstrate the knowledge, skills and judgment required for entry-level practice. In 2010, NCSBN published the results of a 2009 nonexperimental, descriptive study comparing entry-level nursing activities between entry level RNs from the U.S. and from Ontario (Report of Findings from the Comparison of Entry-level Registered Nurses in the U.S. and Ontario,Canada, 2010). The goal of the study was to determine whether there were similarities between RNs in Ontario and their American counterparts with respect to how Ontario RNs answered the 142 entry-level RN nursing activity statements that were used in the American 2008 RN Practice Analysis survey. Newly licensed nurses who had passed the CRNE in the June 2009 sitting were invited to participate in the study. Out of 1,697 RNs invited, a total of 1,688 surveys were mailed due to address issues (Report of Findings from the Comparison of Entry-level Registered Nurses in the U.S. and Ontario,Canada, 2010, p. 1). After adjusting for the return rate of the survey (540 responded to the survey) and removing those who did not qualify for the study, the analyzable response rate was 26.1% (Report of Findings from the Comparison of Entry-level Registered Nurses in the U.S. and Ontario,Canada, 2010). Overall, the report states that results of the data analyses from the study suggested a strong correlation between the entry-level practices of Ontario RNs and their U.S. counterparts. This finding helped to support the Canadian Council of Registered Nurse Regulators' decision to implement the NCLEX-RN exam in Canada. For current nursing students who will graduate in the Fall of 2014 and are eligible to sit the NCLEX-RN exam in 2015, they will have the opportunity to sit the exam theoretically, everyday of the year and in multiple designated test centres throughout the country. No longer will graduates be tied to writing the exam in one of three annual offering times which is currently in February, June and October, and be limited to a fixed number of test centre locations. Graduates will now have the flexibility of selecting which dates and at which test centres they wish to write the exam. Furthermore, the exam is now no longer in a pen and paper format, but is now a computer-based test (CBT). This computer-based test is also adaptive. 2.2. Computer Based Testing (CBT) and Computer Adaptive Testing (CAT) A computer-based test provides a number of benefits over the traditional pen and paper format. It allows for automation in marking, less marking workload and faster feedback regarding how students performed on the test/exam (Lilley, Barker & Britton, 2004). It also allows for more frequent assessments, increased range of assessed knowledge, increased assessment methods and increased objectivity (as cited by Maguire, Smith, Braillier & Palm, 2010, p. 118). The most common type of computer-based test is a linear, fixed length computerized assessment which is a replica of a pen and paper test (Georgiadou, Triantafillou & Economides, 2006). According to Georgiadou et al. (2006), each student receives the same number of questions and the same types of questions. However, this type of computerized testing does not allow for assessing the examinee's ability and performance level. A computer adaptive test provides the added benefit of being a computerized test that is able to provide additional information about the examinee's ability and performance level (Georgiadou et al., 2006). Computer adaptive test (CAT) has its origin in the early 1900's with French psychologist, Alfred Binet (1959-1911) who proposed a scale to measure the ability to think and reason (Georgiadou et al., 2006). Binet developed an IQ test that assessed for intelligence by adapting the difficulty of the questions based on the characteristics of the examinee (Pencils Down, Booklets Closed, 2014). The examinee is presented with a question; if he/she answers the question correctly, a more difficult question will be presented next. If he/she answers the question incorrectly, a slightly easier question will be presented next. Depending upon how each examinee answers the question (correctly or not) determined the level of

48 Anousone Rowshan and Mina Singh: A New Era on the Horizon - Challenges and Implications of the NCLEX-RN Exam in Canada difficulty of the next question that is presented. In this manner, this allowed for an estimation of an examinee's ability (Pencils Down, Booklets Closed, 2014). Although the concept of an adaptive exam is simple, it was difficult to implement until the computer era which has allowed for selection of questions from a pool of questions based on the student's performance as assessed by an algorithm (Pencils Down, Booklets Closed, 2014). Therefore, no two examinees will answer the same set of exam questions. In fact, the questions that are presented to each examinee are tailored to the individual's ability and performance level. The final grade on the assessment is determined by the level of difficulty and not on the number of questions answered correctly. CAT is based on the principles of Item Response Theory (Georgiadou et al., 2006). Item Response Theory is also known as latent trait theory. A latent trait is the characteristic of an examinee that causes a consistent performance on a test; it is not a hypothetical construct, but something, which can be measured (Singh, 2001). CAT allows for assessment of the examinee's ability in relation to the level of difficulty of the test question. In the case of the NCLEX-RN exam, the examiners are trying to measure the performance level or ability level (ability estimate) of the examinee based upon how he or she answers the item test questions. A logit is a unit of measure, which is used to report the relative differences between a candidate's ability estimate and item difficulties (What is a logit?, n.d.). The logit provides a determination of a candidate s average ability to answer the test item correctly and the level of difficulty of the test item (Lavin & Rosario-Sim, 2013). Advantages of a computer adaptive test also include flexibility in test management, immediate availability of scores, increased test security, and increased motivation (Georgiadou, 2006). Administering assessment questions that are appropriate to the ability of the examinee prevents boredom in students who perform at a higher level while mitigating frustrations in those students who are less proficient in answering the questions (Lilley et al., 2004). The key advantage to a computer adaptive test is its efficiency in reducing the time to more than 50% of the time it takes for examinees to complete the test while maintaining the same level of reliability (Georgiadou, 2004, p. 263). An underlying assumption is that graduating nursing students with differing abilities may still acquire entry level competencies necessary to practice safely. The difference in abilities simply means that those who perform better by answering the more difficult questions will have fewer questions to answer to pass the NCLEX-RN exam while those with a lower performance will have to answer more questions of a lower difficulty level to demonstrate their competency to practice at an entry level. This transition from a conventional pen and paper format to using a computer adaptive exam to administer the NCLEX-RN exam occurred in 1994 in the U.S. (Pencils Down, Booklets Closed, 2014). In its anniversary edition of this important event, the Spring 2014 edition of NCSBN publication, In Focus, commemorates the evolution of the NCLEX. With twenty years of experience in administering a computer adaptive test, the NCSBN has had two decades to assess the merits of CAT in delivering NCLEX exam to new nurse graduates. American nursing schools have had ample time to assess the outcome of CAT and prepare their students and graduates to sit for such an exam. Computer based testing has been utilized in other disciplines such as medicine as early as the 1990's in which Loyola University Medical Education Network increased the application of technology in support of the medical curriculum (McNulty et al., 2011). McNulty concluded in their study that CBT has had a positive impact on the medical curriculum and increased student satisfaction. The United Stated Medical Licensing Exam (USMLE) is a computer based (CBT) exam which transitioned from a pen and paper format to CBT in 1999 (Wei, 1999). However, it is nurses who have led the way in utilizing computer based testing technology to administer and assess for entry-level competency half a decade earlier with the introduction of CAT in 1994 (Pencils Down, Booklets Closed, 2014). Computerized examinations are here to stay and nursing is one discipline that has embraced its contribution in assessing the competency of new nurse graduates to practice safely in an entry level position upon graduation. Although a computerized examination for licensure/ registration in Canada is novel, the American nursing experience has demonstrated its reliability and validity since the early 1990's (Pencils Down, Booklets Closed, 2014). With the introduction of the NCLEX-RN and CAT to Canadian nursing graduates, Canadian nurses too have joined the computerized assessment era and must face the growing pains of change. 2.3. NCLEX-RN Exam Development In the Webinar co-hosted by the Canadian Council of Registered Nurse Regulators (CCRN-r) and the National Council of State Board of Nurses (NCSBN) in December 2012 to introduce the NCLEX-RN to Canadian nurses, Aida Wu, the Associate Director of Measurements at NCSBN explained the exam development process (CCRNR - NCLEX Education, 2012). To ensure relevancy of the NCLEX content to the practice setting, every three years NCSBN conducts a practice analysis study to determine the current activities required of new nurses in practice. Included in this study is a comprehensive review of the textbooks and journals that nursing students are expected to study as a part of their nursing curriculum. A Practice Analysis Expert Panel consisting of 10-12 expert nurses utilizes this information and 2 newly licensed nurses to develop activity statements that reflect the job activities that new nurses are expected to perform. This list of statements is then converted into a survey, which is mailed to newly licensed nurses defined as those with less than 6 months post-licensure. Newly licensed nurses are asked to rank the statements based on the frequency of completing the activity and how important the activity is in providing safe client care. From the results of this survey, this information is used to develop the test plan

International Journal of Nursing and Health Science 2014; 1(6): 46-54 49 for the NCLEX-RN exam. 2.4. NCLEX-RN Exam Content The current NCLEX-RN test plan or exam blueprint is a result of the Practice Analysis conducted in 2011 (2013 NCLEX-RN Test Plan, 2012). The current test plan is in effect from April 1, 2013 through to March 31, 2016 (2013 NCLEX-RN Test Plan, 2012). According to the NCLEX-RN Detailed Test Plan (2012) booklet for nurse educators, the test plan is organized into four major client needs categories: Safe and Effective Care Environment; Health Promotion and Maintenance; Psychosocial Integrity; and Physiological Integrity. Safe and Effective Care Environment is subdivided into "Management of Care" and "Safety and Infection Control". Under Physiological Integrity, this is subdivided into "Basic Care and Comfort", "Pharmacological and Parenteral Therapies", "Reduction of Risk Potential" and "Physiological Adaptation". The writing and coding of test items is based on Bloom's taxonomy of cognitive domains with emphasis on higher levels of cognitive abilities such as application, analysis and synthesis (as cited in 2013 Detailed Test Plan, 2012, p.4). Integrated throughout the exam are processes fundamental to nursing such as the nursing process, caring, communication and documentation and teaching/learning. Although specific questions may focus on a client needs category, these integrated processes are present throughout the exam and the examinee must consider them when answering the test question. Physiological integrity represents 38% to 62% of the exam content while psychosocial integrity and health promotion and maintenance represent only 6% to 12% of the exam. Safe and effective care environment represents 26% to 38% of the exam. Table 1 below provides an overview of the eight client needs areas that will be tested on the NCLEX-RN exam and its distribution. Table 1. Content of the 2013 NCLEX-RN Test Plant Based on "Client Needs" (Adapted from Transitional NCLEX Examination Candidate Bulletin for Canadian NCLEX Candidates, 2014, p. 14) Percentage of Content NCLEX-RN Client Needs Category in Test Plan Safe and Effective Care Environment 26-38% Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity 38-62% Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptations 11-17% The NCLEX-RN exam that Canadian nursing graduates will write in 2015 is exactly the same NCLEX-RN exam that will be offered to American nursing graduates (NCLEX Frequently Asked Questions for Canadian Educators & Students, 2013.). Allowances have been made for differences in Canadian terminologies and the metric system. Otherwise, the NCLEX-RN exam is identical. Another feature of the NCLEX that Canadian graduates will need to consider is the multiple format of the questions. These include multiple-choice questions with one correct answer, multiple-choice questions with multiple correct answers, fill-in-the-blank calculation questions, ordered responses and/hot spots in which candidates must locate an anatomical point on a diagram (2013 NCLEX-RN Detailed Test Plan, 2013; Lavin et al., 2013). Additionally, the test item questions may also include the use of multimedia such as charts, tables, graphics, sound and video in which candidates must identify heart or lung sounds (Lavin et al., 2013). 2.5. NCLEX-RN Exam Administration and Delivery Administration of the NCLEX-RN exam has been given to Pearson VUE, the largest commercial testing company and education publisher in the world (About Us, n.d.). Students need to first apply to their respective regulatory body in order to receive an "Authorization to Test" (ATT) e-mail, which confirms the student's eligibility to sit for the NCLEX. Prior to receiving this e-mail, the nurse graduate can register to write the NCLEX with Pearson VUE. However, the ATT is required to confirm the candidate's authorization to write the exam; it also has the candidate identification number and an expiration date in which one can write the NCLEX (Transitional NCLEX Examination Candidate Bulletin for Canadian NCLEX Candidates, 2014). Pearson VUE currently has thirteen permanent testing locations in Canada, with five locations located in Ontario, the most populace province in the country (2015 Canadian Testing Locations & Schedules, n.d.). There are no permanent sites for Northern Ontario. For the NCLEX-RN exam implementation in Canada starting in January 2015, additional temporary Pearson VUE testing sites will be made available to accommodate the large number of graduating nursing students during this transition time. For graduates who register to write the NCLEX from November 3, 2014 to December 31, 2014, thirteen testing centres across the country are currently available. Graduating nursing students may elect to write the exam at a U.S. test centre, if they wish. 2.6. Successfully Passing the NCLEX-RN Exam The 2013 Detailed Test Plan outlines the NCLEX pass or fail decision rules. In the first scenario, the computer stops administering exam questions once it is 95% certain that the candidate's ability is either above or below the passing standard. The second scenario is the maximum length exam in which an examinee's ability levels is close to the passing standard and the computer administers the maximum number of questions which is 275 questions (Lavin & Rosario-Sim, 2013). By the end of the exam, if the examinee's final ability estimate is above the passing standard, the individual passes the exam; if it is below the standard, the person fails the exam. Scenario three is the "Run-Out-of-Time Rule"

50 Anousone Rowshan and Mina Singh: A New Era on the Horizon - Challenges and Implications of the NCLEX-RN Exam in Canada (R.O.O.T.) in which the computer has not determined with 95% confidence certainty and the examinee runs out of time. In this case, the examinee passes the exam if the last 60 ability estimates were consistently above the passing standard and fails if the last 60 ability estimates drops below the passing standard. The ability estimate is predicated upon all previous items answered (2013 Detailed Test Plan, 2012). In December of 2012, NCSBN decided to raise the passing standard for the 2013 NCLEX-RN Test Plan (About NCSBN, 2012) from -0.16 logit to 0.00 logit. A logit is a unit of measurement that reports relative differences between an examinee's ability estimate and test item difficulties (What is a logit?, n.d.). This new standard is an increase from the previous passing standard and will remain in effect throughout March 31, 2016. This new pass rate was revised based on the recommendations of an expert panel and feedbacks from surveys to nursing employers and educators with the consensus of the latter group that those who passed the NCLEX-RN exam were not competent to practice (Talking Points Pertaining to the 2013 NCELX-RN Passing Standard, 2013). 3. Discussion The transition from the Canadian-based CRNE to the American-based NCLEX-RN exam has immediate and longterm implications for nursing students, graduates, nursing faculty and educators. According to Staples and Urban (2014) at the University of Regina, the change has left many nurses, educators and students with questions and various perceptions of what this change means (Transitioning to the NCLEX, 2014). Although it was addressed in an NCLEX workshop that Staples & Urban attended on October 23, 2013 that Canadian RNs would be able to participate in the exam writing and review process, Canadian involvement in the 2013 NCLEX-RN exam version being used for students in 2015 is not apparent. The current exam which will be in effect when Canadian graduates write is based on the 2011 Practice Analysis and CCRNR's announcement regarding the transition to the NCLEX occurred in December of 2011. Linda McGillis Hall, Professor and Associate Dean of Research and External Relations at the University of Toronto's Bloomberg Faculty of Nursing also voiced that Canadian input into the exam will begin with future NCLEX exams as the 2013 NCLEX-RN version has been released by NCSBN (Kovener & Spetz, 2013). The implications for the first group of nursing graduates who will be taking the NCLEX-RN exam in 2015 is greater as this group will in some ways be a test group as to how Canadian nurse graduates fare on the NCLEX and how the current nursing curriculum prepares them. There are numerous implications that such a transition would cause. Many are obvious such as student anxiety about their preparedness to undertake such as exam. There may be concerns over content matter as to whether the US content and the Canadian nursing contents are similar enough. Since tests in nursing schools have been in the pen and paper format, it is understandable that for some, a computer based exam might be intimidating, especially one in which how one answers a question correctly or not determines subsequent questions and the passing scenario that the computer utilizes to determine competency. According to Caputi (2013), it is more imperative than ever for faculty to understand the structure of the NCLEX in order to prepare students for successfully passing it. In the U.S., a school's pass rate on the NCLEX can not only affect its reputation, but more importantly, also its accreditation status (Caputi, 2013; Yeom, 2013). Furthermore, in a study by McFarquhar (2014) on the lived experiences of graduates who fail the NCLEX-RN exam, they experienced not only disappointment, but also depression and avoidance behaviour. Yeom (2013) also noted that failure on the NCLEX-RN caused a loss of self-esteem, guilt, social stigma and financial loss. 3.1. Testing Anxiety The thought of an exam is often enough to cause anxiety in any student. Now, the thought of a "new" exam is likely to create an even greater anxiety. It is reasonable to expect that the first group of Canadian NCLEX examinees will have increased anxiety about the exam. Couple with this is the lack of familiarity with the exam's structure, content, and mode of delivery. To combat undue anxiety requires leadership from nursing faculty to equip students with knowledge about the NCLEX exam. As students and educators understand the nature of an adaptive test, the anxiety should be reduced. Furthermore, students will not have to learn the empirical system or certain American terminologies. Considerations have been made for differences in terminologies and the metric system (NCLEX FAQs for Canadian Educators & Students, 2013). In a study by Flowers, Do-Hong & Davis (2011), students with disabilities preferred CBT to a pen and paper test and believed that they performed better. 3.2. Psychological Domains Measured The NCLEX-RN exam measures primarily cognitive domains using Bloom's taxonomy to code the test items with a focus on the higher cognitive domains (2013 NCLEX-RN Detailed Test Plan - Candidate Version, 2013). Depending upon the nursing school, Bloom's taxonomy may or may not be utilized and faculty and graduates need to become familiar with Bloom's taxonomy and how it relates to learning and testing. 3.3. NCLEX Content The content of the NCLEX-RN exam is different from the CRNE. This difference in distribution of testable material needs to be understood in order that graduates may adequately study the right material. Up to 62% of the content is based on a physiological perspective such as pharmacology, parenteral therapies and physiological adaptation (2013 NLCEX-RN Detailed Test Plan, 2012). There is less focus on health promotion and maintenance, and psychosocial

International Journal of Nursing and Health Science 2014; 1(6): 46-54 51 integrity. Again, nursing faculty will have to reassess and reevaluate their current curriculum to see whether it aligns with the NCLEX content material and whether it is sufficient to meet the requirements of passing the NCLEX. 3.4. Computer Adaptive Test (CAT) The biggest change is in the delivery of the exam. The pen and paper era is over. Now is the era of computer adaptive testing (CAT) which on the surface may appear challenging because of the adaptive nature of the exam. In fact, this is not true. An adaptive test is specifically tailored to each examinee and measures an examinee's ability or performance level (Georgiaou et al., 2006). In fact, the exam is not intended to increase anxiety. Georgiadou et al. (2006) explained that a computer adaptive exam is not intended to discourage low performers or create boredom in high performers. How it works is that depending upon an examinee's ability or performance level, the computer selects subsequent questions tailored to the examinee's ability. For graduates who are high performers, they receive more difficult questions and have to answer fewer questions to achieve the passing standard. For graduates who are low performing, they are given questions that match their level of performance. For this second group of examinees, they need to answer more questions to achieve the passing standard. Regardless of whether an examinee falls into the high or low performing group, each person is given an opportunity to demonstrate that he or she has the minimum competency required for entry-level practice. The difference is that a high performing examinee will finish the exam faster after answering fewer questions. In the final analysis, it is not the score itself, but whether you have passed the standard that determines whether an examinee obtains licensure. Although NCSBN stated that "You are not expected to know how to use a computer before you take the examination.", knowing how to use a computer could only help graduates who are writing a computerized exam (Transitional NCLEX Examination Candidate Bulletin for Canadian NCLEX Candidate, 2014, p.2). It may certainly lessen the anxiety of having to learn one more new thing for someone who has never used a computer, but was expected to use one to write the most important exam of his/her nursing career! Nursing schools will have to consider computer adaptive testing simulations similar to the NCLEX to help prepare their students. This can be an expensive investment on the school's part as computers and commercial programs are needed. The use of standardized tests such as HESI (Health Education Systems Inc.), Mosby Assess Test or the National League for Nursing (NLN) tests have shown to be a predictor of NCLEX-RN success (Yeom, 2013). This may not be feasible to implement at certain schools as the use of standardized tests is not only expensive, but can be time intensive to implement (Homard, 2013). Therefore, nursing faculties must investigate this option to determine if standardized tests should be utilized, which ones are most effective and which ones are permissible based on budgetary constraints. 3.5. Suggestions for Nursing Students, Graduates, and Educators Both faculty and students require an orientation to the NCLEX to demystify it and correct any erroneous preconceived notions. Every educator needs to have an indepth understanding of this exam. Once everyone understands what this exam truly is can they move forward to seeking solutions that will help students and graduates to successfully passing the exam. Canadian nursing schools should look at the research available from their U.S. counterparts on strategies that U.S. nursing schools have used to increase the NCLEX-RN pass rates at their institutions and evaluate its effectiveness and how these strategies may be tailored to a particular Canadian nursing school to help with the transition. A testing policy was developed in one nursing school in Colorado which compared the first-time NCLEX- RN pass rates prior to implementation of the testing policy and after implementation (Schroeder, 2013). A t-test compared the mean NCLEX-RN pass rates for the two groups and found that the pass rate was significantly higher (P.01) in the group of graduates who wrote the NCLEX- RN exam after the implementation of the testing policy (Schroeder, 2013, p. 546). This demonstrated the effectiveness of the testing policy in significantly improving the pass rate. Canadian nursing schools may wish to consider implementing a similar program to help with the transition to the NCLEX-RN in preparing their graduates to successfully pass it on the first attempt. This same school also designated a new administrative position, a retention coordinator, who worked with the faculty to focus solely on improving the school's NCLEX-RN pass rates (Schroeder, 2013). Furthermore, Canadian nursing schools may also consider the use of standardized commercial tests to prepare students if they have not already done so. American studies have also demonstrated some positive correlations with the use of commercial standardized tests, which model after the NCLEX (Yeom, 2013). According to Marsh and Willis (2003), the three pillars of curriculum are content, instruction and assessment (as cited by Kantar, 2014, p. 789). There are differences in content, in particular, in the distribution of material tested. The NCLEX- RN is based on Bloom's taxonomy and hence this poses a question about the adequacy of current nursing instruction. Furthermore, the assessment of whether nursing students and graduates have acquired the necessary entry-level competencies is now a computer adaptive test that consists of a number of different test question formats that incorporates multi-media as a part of the exam is another dimension that faculty and educators must consider when assessing students throughout their nursing education. The role that nursing faculty and educators have in helping their students prepare for successfully passing the NCLEX is immense. However, like any exam, the instructor plays only part of the role in the students' success. Students too have a large role to play in their success by studying the NCLEX

52 Anousone Rowshan and Mina Singh: A New Era on the Horizon - Challenges and Implications of the NCLEX-RN Exam in Canada content material, focusing on the integrated processes that permeates throughout the NCLEX and developing their critical thinking skills and being able to apply, analyze, synthesize and evaluate information they have learned in nursing school to apply to new situations. Students and graduates must focus on Bloom's higher cognitive domains when studying and integrating information because they will represent the majority of the questions (2013 Detailed Test Plan, 2012). Furthermore, the NCLEX-RN exam is not an exam where one should guess due to the adaptive nature of the exam. Graduates should not delay in writing the exam following graduation. Studies have shown that there is an inverse relationship in which delay in taking the NCLEX after nursing school has an effect on NCLEX success (as cited by Homard, 2013). Our neighbors to the south have used an array of strategies to improve the NCLEX-RN first time pass rate from curriculum change, standardized testing and attitudinal changes (Carr, 2011). The stakes are high as American schools of nursing may lose accreditation if a high percentage of their graduates do not pass the NCLEX (Carrick, 2011). According to Carrick (2011), nursing schools may need to revise their academic policies, change their curriculum and assessments, and implement remediation for those at risk of failure while providing support to the entire student and faculty body. Frith, Sewell & Clark (2008) looked at best practices to prepare students. Frith et al. noted that the establishment of a new course, "Integrated Clinical Concepts" provided both academic and non-academic support to students which helped to reduce test anxiety, negative self-talk as well as improving cognitive preparation by reviewing exam content, test taking strategies and practicing NCLEX-like questions. There is much work to be done by both nursing faculty and students from a detailed orientation to the NCLEX to demystify it, to faculty and student development with ongoing support, and improving assessments to predict the students' readiness to write the NCLEX-RN exam. Although there are ethical, legal, cultural, socioeconomic and technological implications, some American schools have adopted a standardized exit exam as a part of graduating from the nursing program (Santo, Frander & Hawkins, 2013). Spurlock, and Spurlock and Hunt in their studies have identified students who are likely to pass, but were unable to identify those with the potential to fail (as cited by Santo et al., 2013, p. 82). 4. Conclusion The effects and consequences of the introduction and implementation of the NCLEX-RN exam into the Canadian nursing landscape cannot be adequately discussed in one paper. The NCLEX-RN exam has the potential for both positive and negative impact. For those who wish to migrate south to gain U.S. nursing experience, a separate licensing exam is no longer required. The NCLEX exam reinforces the importance of nursing schools to keeping abreast of changes in health care. It also challenges each student to live the competency requiring him or her to be a lifelong learner by recognizing that nursing schools cannot teach you all the knowledge and skills you will need; they are there to prepare you to acquire knowledge and to teach you how to learn throughout life (Homard, 2013). A question that the NCLEX-RN poses is whether nursing schools need to teach directly to the NCLEX-RN test plan. Do nursing schools not have a higher mandate? The NCLEX- RN exam only focuses on the entry level knowledge and skills as indentified by a sample of new nurses on a practice analysis study. It does not represent all members of the nursing profession. What about courses such as political activism in nursing? Do these courses have a place in the new curriculum that focuses solely on the NCLEX test plan? There continues to be many more questions than answers in regards to the implications and impact that the introduction of the NCLEX-RN exam will have for Canadian nurses. Another new change on the horizon is that for the purpose of future Practice Analysis Surveys, the entry level period will now be considered as 12 months, not 6 months which have previously been used for prior surveys (Williams, Dickinson & Woo, 2014). There are no quick fixes to help in this transitional phase. There will be growing pains as with all changes. But we must open the doors to discussing and evaluating how these changes can make us into a stronger and more responsive profession to preparing our students to competently and safely care for the clients that we serve while advancing the nursing profession. 4.1. Areas for Future Nursing Research Areas for future nursing research include determining the first time pass rates for Canadian graduates who will be writing the NCLEX in 2015 and its comparison to the U.S. first time pass rates. Studies may also examine the factors affecting Canadian pass rates relative to our American neighbours as well as assessing the importance of standardized testing or the effects of how curriculum changes will affect the first time NCLEX-RN Canadian graduate pass rate. Future studies may also examine how adequate the NCLEX exam prepares graduates for the Canadian health care scene in light of a shift from hospital-based care to home and community care services. Studies may also focus on the implementation of CAT into the Canadian nursing curriculum and the challenges encountered. Canadian research into the implications and effects of the NCLEX-RN exam on the Canadian nursing landscape is in its infancy and the opportunities for research and learning are vast. References [1] 2013 Canadian RN Practice Analysis: Applicability of the 201 NCLEX-RN test plan to the Canadian testing population. NCSBN RESEARCH BRIEF, 47(July 2010). Retrieved July 1, 2014 from https://www.ncsbn.org/14_canadian_practice_analysis_vol60.pdf

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