Dear Dr. Nagle,

The most recent issue of the Canadian Journal of Nursing Leadership on the NCLEX-RN goes far in establishing the historical record of a change that has had a marked adversarial effect on Canadian nursing education. The issues are as raw today as when the decision was announced in 2011. Those of us who bear witness to the decision to implement an American exam, and its aftermath, will be held to account in this historical record. The papers in the issue represent multiple perspectives of a concerned nursing profession; it is heartening that we have not let this go and instead relate more critically than ever to the injustice and advocacy for NCLEX-RN alternatives and for power and governance of the nursing profession in Canada. These perspectives, courageous and bold, invite us to envision a preferred future in how we regulate the new members of our profession.

I recall the moment when I heard the news that a small group of executive directors from the provincial and territorial nursing associations and colleges had made the decision to adopt the NCLEX-RN; shock waves reverberated among nurses and organizations across Canada. There was at the time a widespread petition to revisit the decision, citing the precise concerns that are now present-day realities and documented in the special issue of Nursing Leadership. Boards of elected representatives considered the alternatives, including the option to reverse the decision, but did not.

The decision to adopt the NCLEX-RN is today, as Guest Editor Barb Mildon describes, "the defining problem for Canadian nursing"; the canary in the coal mine for the future of governance and self regulation of Canadian nursing. Five years of NCLEX-RN experience with mounting evidence and calls for change point to the lack of commitment to governance and collaboration at organizational levels essential for critical reflection on issues, conflict and alternatives. The NCLEX-RN decision is about power and governance in the profession and discipline of nursing in Canada. The COVID-19 pandemic is a powerful reminder of how context and culture matter to the nursing profession, and how we collectively express our values and practice.

As an educator, I witness the impacts of this exam including undue expenses for students and programs and the lack of information on how graduates fare with this exam over time – notably those who are not successful on first or second attempts: Where are they? Who are they? How can we understand or assist them in what must be a most demoralizing entry to the profession?

Issues of public trust and safety raised in several articles as most significant. Citing their commitment to enhanced transparency, regulators propose publicizing exam results: how will this inform the public about the quality of a nursing education program in all Canadian contexts and cultures? And will newly prescribed regulatory policies on publicizing program review results lead to enhanced transparency or an erosion of public trust in Canadian nursing education?

To the future: nurses must be prepared with competencies to govern their organizations, including regulatory colleges. Roles must extend beyond business acumen to a deep understanding of the profession, including the regulatory mandate of a commitment to public health and safety. Most important is the understanding of power in relationships and organizations that can silence voices and perspectives essential to the profession and public trust. As educators, we prepare students at undergraduate and graduate levels for leadership in organizations, and they learn about the history and mandates of nursing organizations in Canada, and globally.

As the National Council of State Boards of Nursing (NCSBN) is planning the launch of the "Next Generation NCLEX Project" in 2023, with an anticipated global reach, the time to bring the voices of reason and progress together for a Canadian alternative to the NCLEX-RN and to make sure we are not part of the Next Generation initiative is now (NCSBN 2020). The Canadian Examination for Baccalaureate Nurses (CEBN) is visionary and eloquent in its "fitness of purpose"; the exam blueprint synthesizes the essential categories most relevant to the context, culture and quality of Canadian nursing education. The categories of evidence-informed knowledge worker, entry-level clinician, communicator and collaborator and health professional/change agent fit the purpose of a BSN preparation of a Canadian nurse. I envision a generation of board members and organizational leaders who will stand up for this high standard.

I applaud the multiple perspectives of those who have contributed to a deeper understanding of what has occurred and inspired a way forward. The voices in this issue have sparked renewed momentum in those who are determined to move forward with a Canadian solution, and this should be a priority agenda for all of us.

Susan M. Duncan, RN, PhD
Professor and Director
School of Nursing, University of Victoria
Victoria, BC

Dear Editor,

The Guest Editorial titled "Voices Raised: The NCLEX-RN Experience in Canada," by Barbara Mildon, provides an excellent overview of the critical issues triggered by the NCLEX-RN reality impacting nursing and healthcare in Canada.

The problems caused by the transition to and implementation of the NCLEX-RN system are real. There has been sufficient "water under the bridge," experience and evidence, to confirm that the concerns and facts raised are neither perceptions nor based on emotion. They are legitimate issues that must result in definitive action. The warning bell has been sounded.

The obvious courses of action: Identify a solution to the NCLEX-RN problem that is agreed upon by all key stakeholders, or if that cannot be attained, then the regulatory structure must be totally overhauled and redesigned.

We all have friends, colleagues and relatives who live in the United States. That being said, we all agree, both Canadians and Americans, that the structures and processes of our healthcare systems are fundamentally different, the cultures of healthcare are different. Examinations reflect values and the structures, processes and desired outcomes around which they are built. Some might say that if an exam is evidence-based, then values, structures, processes and outcomes are not reflected. This is absolutely incorrect and is evidenced, for example, by the impact of NCLEX-RN on Francophone students.

Following two invitations by the CJNL's editor-in-chief, Dr. Lynn Nagle, the fact that the CCRNR refused to contribute to this issue raises a red flag. Why the wall?

Health is about partnership and collaboration. Ensuring quality and safety is about partnership and collaboration. In fact, one of the CCRNR objectives is: establish external liaisons and partnerships that position the council to address professional nursing regulatory matters. The College of Nurses of Ontario states: "The college works in partnership with employers, educators and the government so that everyone in Ontario benefits from quality nursing services" (College of Nurses of Ontario 2020). However, the actions of our regulatory partners do not demonstrate that commitment. The self-isolation of CCRNR, their reluctance to partner, reluctance to demonstrate willingness to collaborate and move towards a mutually agreeable solution are discouraging and unacceptable. Do they feel threatened to risk working in partnership?

Self-regulation is indeed a privilege. When it is abused through unilateral decision-making with impacts such as those documented in this series of articles, it clearly points to the fact that changes are necessary. We must come together as a nursing profession with collaboration from key partners and identify a solution to the NCLEX-RN reality. If this is not possible, then regulatory changes must be initiated. The question must be asked: Is our current nursing regulatory system beyond repair?

This publication is a call to action – we either demonstrate that as a profession we are capable of collaborating or we take steps to trigger an overhaul of the regulatory system. It is about protection of the public, it is about protection of quality health and care, it is about protection of the integrity of nursing.

Wendy Nicklin, RN, BN, MSc(A), CHE, FACHE, FISQua, ICD.D
Healthcare Consultant,
Corporate Director
Ottawa, ON

It is Time to Quit the NCLEX

I read with much interest the recent issue of the Canadian Journal of Nursing Leadership and wish to congratulate the journal for focusing on this distressing issue. I have followed the move to NCLEX-RN with mounting consternation and sadness – my consternation arising from the impact of this move on nursing students, nursing workforce supply, education, public perception, professional evolution and, ultimately, public safety. My sadness arises from the erosion of good regulatory governance and failure of accountability.

Many interested parties have documented the impact of the move to an American exam; one developed only in English and targeted towards a 3-year, acute–care-focused training in an environment of imperial measures, US pharmacology and law, and culturally different from the Canadian perspective. The regulators' response to address the impact of poor French translation, high failure rates among francophone students, lack of French language preparatory materials, and the costs of rewrites (with payment in US dollars and often necessitating travel to the US to write) shows total disdain for aspiring registrants. It has resulted in a loss of resources to the healthcare system as graduates seek other careers – or find other work while waiting to rewrite. It has also led to a shortage of French-speaking nurses in provinces such as New Brunswick, a situation that leaves a large segment of the public at risk.

Members of the public, now made aware of the situation and the fact that nursing is the only health profession writing an American licensing exam, are incredulous. They ask: Why? How … did this happen? What is being done about it? There is no good way to answer this. It saddens me to admit that poor governance decisions and lack of accountability led to and perpetuated this situation.

Boards are meant to make strategic, evidence-based decisions that promote, sustain and enhance safe practice in an evolving, forward moving Canadian environment. Mandatory writing of the NCLEX-RN promotes free movement of nurses to the United States, which has an ever-growing shortage of nurses and already depends on twice the number of internationally educated nurses than Canada does. It also promotes teaching to the exam, thus eroding our academic foundation grounded in primary healthcare. The decision to move to NCLEX-RN has also added to the growing scepticism of the health professions' ability to self regulate.

If Canadian nurse regulators insist on continuing to use this exam, they will continue to fail their stakeholders, especially the public and Canada's potential future nurses. A 2017 open letter by the Canadian Nursing Students' Association declared that "research suggests that 81% of surveyed Canadians believe that our nurses should be tested with an exam that uses Canadian content. This speaks to public concern regarding the current entry-to-practice exam for registered nurses in Canada." The students further stated their concern that their education was already being altered to reflect the competencies covered in the NCLEX (Wiltshire 2017).

Good governance demands that boards uphold public confidence by ensuring that professional standards are in place and that care will be safe. Having fewer graduates practising in Canada and enabling a more US-centric curriculum jeopardise safe care for Canadians.

Surely, we have the capacity to regulate nurses by using Canadian tools and processes. Students, nurses, the public and others see the need for a made-in-Canada solution. This could be an entry-to-practice exam, a school exit exam or graduation from a Canadian nursing accredited education program. We should not be so tied to the past to fail to look at Canadian alternatives. As an international consultant, I would like to return to upholding Canadian regulation as an example for others. It is time to return to ensuring a Canadian approach to nursing regulation. It is time to quit the NCLEX.

Judith A. Oulton
International Consultant, Past President, NANB
Past CEO, CNA and ICN
Tatamagouche, NS

Dear Editor,

It is hard to believe that it is almost 10 years since the nurse regulators in Canada decided to move to the NCLEX exam as the entry to practice (ETP). This was a major shift away from the long-standing Canadian exam, which reflected the competencies needed by the regulators to meet ETP. During the first announcement (I remember it like yesterday) to switch to the NCLEX, I was the president of the Canadian Nurses Association (CNA). The CNA board, and myself as the president, spoke out loud and clear as to why it was a very bad policy and practice decision for Canada. By moving to a US-based ETP exam, we ask our trainees to prepare to meet the US competency requirements, which are based on a very different, more narrow view of nursing practice. Nurses and educators joined us and expressed their concern; now, 10 years later, some of those concerns have become a reality, as is documented in this issue.

I know from both my Canadian and global experiences that no leadership would survive without listening to its members (although the regulators claim that nurses are not their members). If the regulators had been political appointees, they would have been thrown out of office long ago. If they were business, academic or healthcare executives, none would have survived 10 years of continuous concern and compromise to the supply and quality of nurses graduating in Canada. In the decade prior to this change, nurses were accountable to meet the practice requirements in the Canadian context, not the US.

How were the regulators able to survive without listening to nurses and the healthcare community, given their supposed commitment to: (1) public protection, (2) self-governance and (3) accountability? Let's examine each of these issues.

The ethos of professions such as nursing is to serve the public and those who need our services. The Canadian Council of Registered Nurse Regulators (CCRNR) tagline says "Promoting excellence in professional nursing regulation." Although this is a very important statement, I challenge the 250,000+ RNs and policy makers in Canada to consider how it is achieved if the testing of nursing knowledge and competencies is done through the NCLEX, of which the American nursing community is the primary user. It is well established that both our educational programs and requirements for the baccalaureate ETP are designed to create a more educated and higher-calibre population of nurses that is superior to US nursing students. So how can the CCRNR "promote excellence in professional nursing regulation" when it could have a much higher level of ETP and be more culturally sensitive to our reality? I suggest that the regulators are not delivering on their mandate when it comes to ETP.

The nursing profession and other professions made the argument that the public will be better served if the regulatory colleges are "self–governed." Although I agree with the concept, it begs the question: What does it mean?

Self-governance, self-government, or self-rule is the ability of a group or individual to exercise all necessary functions of regulation without intervention from an external authority. (Wikipedia 2020)

The colleges claim that they execute this mandate by having an elected council (board). We know that a decision to hand over our ETP testing is a bigger issue than just the "council/board" decision. It is well outlined in the papers in this important issue that there was no consultation with educators, system leaders or other important groups, including the public. It still begs the question: If it is such a "great idea" to have our ETP exams conducted within the context of a different system altogether, why have no other healthcare professional councils, whose memberships are much smaller than nursing colleges, not gone down this path? Furthermore, the final "tacit" decision that gave limited decision making for the small jurisdiction was made by CCRNR and in many ways was a decision by the large jurisdictions; the smaller jurisdiction did not have enough power or influence to challenge this decision. The essential question is: Who is CCRNR accountable to? CCRNR's membership comprises the CEOs of the jurisdictional regulatory bodies. As far as we know, the CEO serves at the pleasure of the board and is to execute policies set by the regulatory councils, not vice versa.

This brings me to the final question: How is it possible that for 10 years regulators were able to maintain this decision and choose not to comment or respond to the concerns about this important issue? I do want to emphasize that the Canadian nursing regulatory system is overall a good one and takes its responsibility seriously. But the decision to farm out the ETP exam to NCLEX was definitely not one of their better ones.

We need to understand that the only accountability the jurisdictional regulators have is to government. But if we truly examine the professional commitment to public protection and self-regulation, then this year, the "Year of the Nurse and Midwife," I hope that regulators, governments and others will wake up, revisit this decision and make a better one that serves Canadians. The public and the profession deserve better.

Judith Shamian
President Emerita, International Council of Nurses
Geneva, Switzerland

Dear Dr. Nagle,

Thank you for this special issue of the Canadian Journal of Nursing Leadership, focused on the NCLEX-RN.

Having been at the board table for the College and Association of Registered Nurses of Alberta (CARNA) when the decision to move to the NCLEX-RN was announced, I have some insights into some of the factors that led to the adoption of the exam. I think there are lessons we must learn from the experience.

I read Kirsten Woodend's article with empathy – I shared many of the same feelings of failure. The initial shock around the announcement in my first two months as president-elect on the CARNA Council drove me to ask many questions. I learned that the Class A members of the Canadian Council of Registered Nurse Regulators (CCRNR) – the CEOs employed by the provincial/territorial regulatory councils – had identified a number of issues with the paper and pencil exam provided by CNA at the time. These concerns revolved chiefly around exam security, the limited number of versions, the challenges inherent in shipping a paper exam across the country, and the limited windows of time for writing the exam. The perspective of the CCRNR was that the CNA (and ASI) had been insufficiently responsive to these concerns, which prompted CCRNR to move to a request for proposal (RFP) for a new exam. It was CCRNR's belief that they had the mandate and the authority to move forward and make the decision at the end of the RFP process, and simply let their councils know about what had been decided.

Indeed, my review of the CCRNR bylaws at the time revealed that they had indeed granted themselves this authority – a revelation that was a surprise to many. From the 30,000 foot view, one needs to see how a stand-alone national structure like this evolved: regulation of the profession is provincial/territorial, but many other structures (trade and labour mobility agreements, for example) that intersect with regulation are national in scope. CNA could not take on this national role, because CNA has no regulatory authority. Add to this the reality that elected jurisdictional presidents and councils come and go, but CEOs of the jurisdictional regulatory bodies most often remain in their positions for many years – and one can see how these individuals might build a structure that reifies their belief that ‘they know best’, and I would even be willing to admit that in some cases this may be true. In my view, however, the governance structure of CCRNR enabled an ‘end-run’ around the rigorous debate and decision making that should have occurred around regulatory council tables.

Once the exam vendors had been engaged by CCRNR, then the individual councils were expected to sign the contracts that we had been committed to. There were two parts of this process that were deeply concerning: in order to review the contract, we were required to sign strict non-disclosure agreements, forbidding us to speak to anyone outside our own council about what the contract contained. Second, we were subject to the ‘domino effect’. We were told that all councils across the nation were signing the contract and that in the interests of harmonized regulatory requirements, it was important that we sign on.

Even if this decision had been the right one – it remains my considered opinion that the decision-making and communication processes were deeply flawed. So, what have we learned that can inform our careful consideration of the future of the entry-to-practice exam?

First, we need to talk to each other, ask lots of questions, become informed about other structures that may be constraining our decision-making authority, and consult with stakeholders who are affected by the decisions we make. Any process that requires our silence, or makes us feel like we ‘have no choice’ should be immediately suspect. Second, we must ask: is it time for a national regulatory framework? The CCRNR is not wrong in emphasizing national consistency from a regulatory perspective. Indeed, it may be that jurisdictional regulatory structures become obsolete as we move into a digital healthcare future. The CCRNR is also not wrong in asserting that a national exam should reflect the state-of-the-art in high stakes exams (computer-adaptive testing). However, for me this begs the question: do we still need a national exam for graduates of rigorously approved (and accredited) nursing programs? As MacMillan (2020) reflects, perhaps our historical "mental models" about the need for a national exam do not serve us in today's context. However, I would be remiss if I did not mention the alternative perspective that several nursing faculty have shared with me (anecdotally): they tell me they have never seen students take an exam so seriously, or study so hard in preparation. I suppose to some that could be construed as a good thing, and as a reason to keep an entry-to-practice exam. However, I can only imagine how much better the public and the profession would be served if all that effort, time and resource was devoted to preparation for an exam that actually reflected the competencies of Canadian nursing practice.

Finally, it is very unfortunate that the CCRNR declined the opportunity to contribute to this discussion. I would have appreciated their perspective on two questions that must be front and centre as we consider the future: is the public safer, and is self-regulation strengthened as a result of adopting this exam? Evidence from the US, referred to in this issue, seems to indicate that the answer to the first question may be ‘no’. From my perspective, an exam that purports to strip out context is – by design – ignoring the source of most threats to patient safety: the context of care. Is the Canadian public served, and self-regulation strengthened by the ongoing erosion of the francophone nursing workforce? Clearly not. Is the Canadian public served, and self-regulation strengthened by the expenditure of scarce educational resources on preparing students to pass an exam that ignores many of the competencies we consider essential to practising our profession in Canada? Surely this answer is also ‘no’.

Guerrette-Daigle and colleagues (2020) described the journey since 2012 as rocky and difficult. Sometimes difficult journeys get us to a better place, and sometimes they don't. No matter where you stand on the issues around the NCLEX-RN, the lessons of the past 8 years must inform the next steps in our journey, together.

Shannon M. Spenceley, RN, PhD
Associate Professor, Associate Dean,
Faculty of Health Sciences
University of Lethbridge
Past-President, CARNA (2013–2016)
Lethbridge, AB

Dear Editor,

My entry into retirement, following years in nursing education, coincided with rumours, then actions, about Canadian nursing students being required to use the American nurses' entry to practice examination (NCLEX-RN). I was very concerned about Canadian nursing education taking that direction.

At meetings I attended, I was aware that nurse educators seemed to feel somewhat helpless. Some felt very strongly that such a move should be avoided, while others seemed willing "to go along to get along", likely feeling they simply had no other choice.

When I learned more about the actions of the Canadian Council of Registered Nurse Regulators (CCRNR) and their apparent determination to avoid consultation with nurse educators and other nursing policy makers, I was stunned. I realized that Canadian nurse educators and nursing students who wanted to stick to a Canadian exam were going to be defeated in their goals. I tried to find out more about the council of people who were making these decisions. I consider this unilateral move on the part of such a powerful committee to be unethical. This also raised questions about their motives for ‘taking charge’ without the input of those who know the business, that is, nurse educators, nursing policymakers and nursing students.

The fact that Canadian nursing students have suffered from the arrangements CCRNR members have agreed to has clearly led to significant harm. Those harmed include nursing students who failed these exams, not due to their lack of ability but due to the exam's bias toward American healthcare, an examination structure that was foreign to Canadian students and inadequate French translation of the exam for Francophone students.

As a scholar and teacher of Canadian healthcare during my years at the University of Alberta, I believe the absence of attention to Canadian healthcare in a nursing education program would be a significant loss. The model of our healthcare services depicts the values of Canadian society, hence, it is crucial that nursing students not only study Canadian healthcare for their final exam, but also appreciate the valuable knowledge it imparts in the process. Clearly, this cannot happen with an American-based program and exam.

Finally, through my years as dean of nursing at the University of Calgary, then director of the School of Nursing at the University of Victoria, I was a strong pursuer and supporter of baccalaureate entry-to-practice for nurses, challenging two different provincial governments to move from diploma programs to degree programs. Settling for the NCLEX-RN, which is designed to test both diploma and degree students, is to diminish the knowledge and skills that are critical for baccalaureate degree nursing students. Furthermore, an exam created by an American nursing group cannot address Canadian nursing practice, including the ethical domain articulated in our Canadian Nurses Association's 2017 Code of Ethics for Registered Nurses.

I applaud the efforts of the Canadian Association of Schools of Nursing to build a Canadian nursing examination that reflects our unique values and can provide Canadian graduating students with a fair and appropriate exam. I wish all involved in Canadian nursing education an easy way to extricate themselves from the NCLEX-RN toward a refined Canadian alternative.

Janet L. Storch, RN, BScN, MHSA, PhD
Professor Emeritus, School of Nursing
University of Victoria
Victoria, BC

Re: Canadian Journal of Nursing Leadership 32(4) 2019

It was excellent to see the variety of perspectives on the NCLEX-RN in your recent issue. Self-regulation is critical, in part, toward ensuring that registered nurse entrants can demonstrate the knowledge and decision-making ability to provide safe practice within the Canadian healthcare and population context. May and Singh-Carlson (2020) point out that the NCLEX is not a fit for the Canadian nursing licensure in two significant regards, 1) a registered nurse in Canada requires a baccalaureate degree as entry to practice rather than an associate degree or diploma (with the exception of Quebec), and 2) the exam does not cater to the Canadian healthcare system. We would add that the NCLEX-RN is a particularly poor fit for nursing practice in rural and remote Canada, where over a quarter of Canada's population live and access healthcare. The NCLEX-RN primarily tests the preparation of nurses to work in acute-care settings in medical-surgical areas at urban hospitals.

In rural and remote communities, nursing practice, even in acute-care facilities, is in and of the communities. Here nurses talk about how they come face-to-face every day with implications of the social determinants of health in the lives of those they care for, such as issues of poverty, poor housing, food insecurity, unemployment and institutional racism. Nurses need to take these into account as they are a crucial component of patient safety in rural and remote settings. Additionally, and importantly, nurses in rural and remote settings need to provide care with cultural humility, while building on a deep understanding of the historical and generational trauma experienced by so many of those for whom they provide care. Nurses, therefore, have to incorporate not only the clinical aspects of patient safety but also understand the uniquely Canadian social and cultural context in which they build relational trust with patients. The NCLEX-RN does not address these aspects of Canadian nursing.

Canadian schools of nursing strive to graduate competent, entry-level generalists capable of health promotion and disease prevention for individuals and communities, as well as sound clinical judgments and appropriate action in acute situations. In small communities, a single registered nurse (RN) may have this breadth of responsibility under the umbrella of a single employment situation, and for nurses in Canada's rural and remote settings, this is often with little in-person support. Graduates are also educated within an ethos of universal accessibility and are taught to value the tenets of the Canada Health Act. We echo here the assessment of Campbell and colleagues (2020) that the NCLEX-RN represents a "misalignment with the principles, context and desired outcomes in the Canadian healthcare context."

We have found that the critical decision-making that includes multiple contextual factors is not sufficiently incorporated into the type of questions represented in the NCLEX-RN. Canadian nurse educators and students have adapted their approaches to improve NCLEX exam-writing skills through the incorporation of similar questioning and testing throughout curricula. We think however, that this moves away from rewarding clinical decision-making that incorporates contextual factors and is disadvantageous particularly for those who think in more complex ways. The concerns voiced by Campbell and Rankin (2009, 2017) about how the social organization of knowledge serves to structure nursing practice in ways not perhaps originally intended are cogent when considering the educational implications of the NCLEX-RN as a licensure exam.

Adapting curricular content and methods of examination to mimic the American approach has been challenging and should be unnecessary when preparing graduates for Canadian practice. For example, the NCLEX-RN demands memorization of lab values, while clinical decision-making for safe care requires knowing the significance of variations in lab values and the actions that need to be taken. This is particularly so in situations without specialist back-up as occurs in many small rural and remote settings.

As well as disadvantaging francophone nursing graduates, as has been eloquently demonstrated in this issue, the NCLEX-RN presents barriers to nurses educated and living in smaller urban or rural centres. An example comes from our own School of Nursing at UNBC. For students of our BScN program at the regional campus in Terrace, BC, opportunities to write the NCLEX-RN can lead to significant expenses beyond the cost of writing and potentially rewriting the exam. If they miss the opportunity to write through a travelling exam-writing centre, they must travel 1,000 kilometres to a permanent exam centre in Vancouver, BC, or elsewhere. This is costly to the graduate and dramatically delays licensure and employment as an RN. In Terrace, due to this difficulty in access, approximately 50% of last year's graduating class remain in provisional RN roles.

We do believe that a standard examination is important to test the requisite competency for entry to practice. We believe that the Canadian Examination for Baccalaureate Nursing (CEBN) has great promise in this regard, particularly if offered electronically, three times per year, and accessible to students in more rural areas of the country as the previous Canadian Registered Nurse Examination was. The CEBN has the potential to better reflect the Canadian context and relevant content, proportionately represented to reflect the realities within which new graduates will work. Such an exam is especially important to measure the preparation for safe practice and sound judgment of those who will work in rural and remote communities. The option of the CEBN upon exit from baccalaureate programs is attractive and likely can show graduates' abilities to provide safe care as well as the NCLEX-RN purports to. However, it would be critical that provincial regulators recognize the CEBN for registration across the country, thus providing for cross-provincial registration.

Sincerely,

Lela Zimmer, RN, PhD, Associate Professor, Undergraduate Nursing Programs, Coordinator, School of Nursing, University of Northern British Columbia, Prince George, BC

Gwen Keeler, MScN, RN, Senior Lab Instructor, School of Nursing, University of Northern British Columbia, Prince George, BC

Martha MacLeod, RN, PhD, Professor, School of Nursing and Northern Health, UNBC Knowledge Mobilization, Research Chair, University of Northern British Columbia, Prince George, BC

References

National Council of State Boards of Nursing (NCSBN). 2020. Next Generation NCLEX Project – Next Generation NCLEX. Retrieved March 12, 2020. <https://www.ncsbn.org/next-generation-nclex.htm>.

College of Nurses of Ontario (CNO). 2020. About the College of Nurses of Ontario. Retrieved April 14, 2020. <https://www.cno.org/en/what-is-cno/>.

Wiltshire, C. 2017. Open Letter to CRNM, CARNA, CRNBC, and NANB. Canadian Nursing Students' Association. Retrieved March 17, 2020. <http://cnsa.ca/wp-content/uploads/2017/01/03.17.17-CNSA-response-to-NCLEX-concerns.pdf>.

Wikipedia. 2020. Self-governance. Retrieved March 17, 2020. <https://en.wikipedia.org/wiki/Self-governance#citeref-FOOTNOTES%C3%B8rensenTorfing200943_5-0>.

Guerrette-Daigle, L., V. Landry, S. Harrison, S. D-Hendriks, F. L. Marquis and L.M. Auffrey et al. 2020. The NCLEX-RN as an Entry-to-Practice Exam in New Brunswick: The Rocky Road Story of Francophone Candidates to the Nursing Profession. Nursing Leadership 32 (4): 74–80. doi:10.12927/cjnl.2020.26099.

MacMillan K. 2020. Perspectives on the Need for a Nursing Entry-to-Practice Examination in Canada. Nursing Leadership 32 (4): 12–6. doi:10.12927/cjnl.2020.26106.

Campbell, D. T., K. Penz, H. Velenberg and M. Campbell. 2020. A Closer Look at the Introduction of the NCLEX-RN Registration Exam in Canada. Nursing Leadership 32(4): 46–56. doi:10.12927/cjnl.2020.26102.

Campbell, M. L. and J.M. Rankin. 2017. Nurses and Electronic Health Records in a Canadian Hospital: Examining the Social Organisation and Programmed Use of Digitised Nursing Knowledge. Sociology of Health & Illness 39(3): 365–79. doi: 10.1111/1467-9566.12489.

May, K.A. and S. Singh-Carlson. 2020. The Adoption of NCLEX-RN in Canada: A Failure of Leadership at the Intersection of Nursing Regulation, Education and Practice. Nursing Leadership 32(4): 57–65. doi:10.12927/cjnl.2020.26101.

Rankin, J.M., and M. Campbell. 2009. Institutional Ethnography (IE), Nursing Work and Health Care Reform: IE's Cautionary Analysis. Forum: Qualitative Social Research 10(2): article 8. doi:10.17169/fqs-10.2.1258.