LANG Committee Meeting

    Pursuant to Standing Order 108(3), we are studying the issues related to French-language training in the nursing field in Canada.

    Since we have been delayed by the vote in the House, each witness group will have 40 minutes.

    We are pleased to welcome this morning Ms. Cynthia Baker, executive director of the Canadian Association of Schools of Nursing; Ms. Michelle Lalonde, assistant professor, School of Nursing, University of Ottawa; Mr. Pierre Godbout, director, School of Nursing, Université de Moncton; Ms. Suzanne Durocher-Hendriks, assistant professor, School of Nursing, Edmundston Campus, Université de Moncton; and Ms. Sylvie Larocque, director, School of Nursing, Laurentian University.

    Welcome. You will have the floor for a total of about 12 to 15 minutes, time that you will have to share. We will then go around the table. That should take about forty minutes.

    Let us proceed with the first presentation.

    Hello, Mr. Chair and committee members.

    My name is Cynthia Baker and I am the executive director of the Canadian Association of Schools of Nursing, the CASN. The CASN represents 94 Canadian nursing schools that offer bachelor or graduate nursing programs.

    During my presentation, I will provide an overview of the problem, its source, and possible solutions. My colleagues can then briefly outline the impact of this problem on their respective schools and regions.

    Let us begin with the problem.

    We are here today to discuss the threat to French-language nursing training outside Quebec and the resulting impact on the care and services offered in French in minority communities.

    The source of the problem is the adoption of the U.S. nursing entry-into-practice exam, the NCLEX-RN, and specifically the problems with its translation and the lack of related preparatory material in French.

    Starting in January 2015, regulatory bodies across Canada excluding Quebec adopted the U.S. nursing entry-to-practice exam, the NCLEX-RN. This exam replaced the bilingual Canadian exam, which was created a long time ago by the Canadian Nurses Association.

    The reason the professional boards cited for this change was that the Canadian exam was a paper-and-pencil exam, whereas they wanted to have an exam that could be administered electronically, a computerized adaptive test, so it could be administered more frequently and results would be available more quickly.

    The adoption of this exam has had certain consequences.

    First, the pass rate among francophones plummeted and has remained abysmal. In 2015, just 27% of francophones passed the exam. The year before that, the pass rate for the Canadian exam at the Université de Moncton was 93%, well above the national average. Its pass rate then dropped to 30% in 2015.

    Graduates who have already written the exam in French warn students about the poor French translation of the exam. As a result, those students are now choosing to write the exam in English. They are also making that choice as a result of the lack of preparatory material in French.

    Graduates feel therefore that they have no other choice than to write the exam in English. Some have even stated to the media that if they had known that they would have to write the exam in English in order to pass, they would have studied in English. They would have enrolled in an English-language nursing program.

    The NCLEX-RN is no doubt affecting the number of students in French-language nursing programs and in turn the number of new francophone nurses who can serve the francophone public.

    This is a vicious circle. The poor translation of the exam and the lack of preparatory material for the French-language exam result in a low pass rate. As a result, fewer francophone nurses are entering the francophone labour market. The reduced number of new francophone nurses offering health care services in French inevitably impacts health care services for francophones.

    We recognize that the training, education, provision of care, and regulation of nursing care fall under provincial and territorial jurisdiction. We consider this to be a national problem, however, related to the provisions of the Canadian Charter of Rights and Freedoms. Moreover, the Consortium national de formation en santé or CNFS, a national health care training consortium, has made significant investments in French-language nursing programs outside Quebec in order to support the provision of care and services in French to francophone communities.

    That summarizes the consequences.

    Let us talk about the translation now.

    The U.S. suppliers of the exam, the National Council of State Boards of Nursing, or NCSBN, had the exam translated by Geo Group Corporation, located in Madison, Wisconsin, in the United States. This group translates documents into more than 150 languages. It must be noted that producing a suitable translation of a high-stakes exam such as this is a complex process, requiring adaptation rather than translation, and we have that expertise here in Canada.

    The CASN analyzed the translation of the NCLEX-RN exam. Our analysis identified serious weaknesses in the design and the process. For instance, there is no preparatory material in French. Yet a great deal of student preparation is needed to pass the NCLEX-RN exam. To make sure students pass, the schools in the U.S. invest large sums of money in the huge commercial industry that sells preparatory material in English. The NCSBN is major player in this commercial industry. There is tremendous need for that kind of preparatory material, and it is even greater in Canada than in the United States. In fact, two-thirds of the skills required for certification in Canada are not assessed by this exam or are only partially assessed. Moreover, from 17% to 23% of the exam questions assess nursing care based on the American health care context.

    Since the francophone market is much too small to be of interest to the industry that produces the preparatory material, no resources are available in French.

    Although the pass rate among anglophones dropped from 87% to 69% in 2015, the investments in the various preparatory resources have really paid off. The pass rate among anglophones has risen since most schools started purchasing commercial preparatory resources. Unfortunately, the francophone candidates do not have access to those resources.

    I will now turn to the solutions.

    Multiple national and provincial groups in Canada have written to the executive director of the NCSBN to suggest solutions, such as providing exam questions in English and in French, translating the preparatory resources into French, or developing a complete glossary, because the current glossary is truly appalling. The executive director refuses to acknowledge the problems related to this exam, denies the need to find a solution, and offers a different version of the facts. It is therefore unlikely that he will make an effort to solve the problem.

    Last November, the 94 schools across Canada that belong to the CASN passed a unanimous resolution stating that the situation is unacceptable and that it is contrary to Canadian values and the interests of Canadians.

    It is our understanding that the professional bodies have begun negotiations to renew their contract with the NCSBN, which expires in December 2019.

    The CASN members are calling for the development of a Canadian and bilingual entry-into-practice exam. The CASN would be pleased to work with the professional bodies and to provide its expertise in the development of that exam.

    Thank you, Ms. Baker.

    Mr. Godbout, you have the floor.

    Hello.

    My name is Pierre Godbout. I am the director of the School of Nursing, which offers programs at three campuses: in Moncton, Shippagan, and Edmundston, which my colleague is representing today.

    The School of Nursing is the only institution east of Quebec that offers a bachelor of nursing in French. The school has a rich tradition, having marked its 50th anniversary about two years ago. So we have been training nurses for a long time.

    The last time the Canadian exam was given, the pass rate was about 93%; the rate was similar in the years prior. The pass rate was high and employers made favourable comments. In 2015, when the new exam format was introduced, the class had a pass rate of 32%. That was an insult to us since our students had worked long and hard throughout their bachelor program. In 2016, the results were similar, with a 39% pass rate. Things have not improved.

    As a result, students have to write the exam several times, which is very problematic since it costs about $450 each time. Some students in the class of 2015 wrote the exam up to six times. It took two years for the pass rate of that class to reach about 88%. The students have until the end of May to complete it.

    In New Brunswick, programs have to be approved by the Nurses Association of New Brunswick to ensure they meet standards. They must also be approved by the CASN. Our programs therefore meet the training requirements of both the provincial body and the national body. So this exam was a huge insult to us.

    It is also very important to remember that New Brunswick is an exception, owing to its francophone population. We are working very closely with the Nurses Association of New Brunswick to find solutions. That is why we are here today.

    Thank you.

    Thank you very much.

    Ms. Lalonde, you have the floor.

    Hello.

    I am Michelle Lalonde, assistant professor in the French-language program at the University of Ottawa.

    The University of Ottawa offers a bachelor of nursing in English, in French, and as an immersion program. We have the same admission criteria for all programs. Our programs have been approved for five years by the CASN.

    Since the NCLEX-RN exam was introduced in 2015, there has been a drop in the number of francophone graduates from the University of Ottawa who have written the exam in French. The pass rate has been below 40%. In 2016, just 15.8% of our students wrote the exam in French, and the pass rate was 39%. In 2017, it is expected that 64% of students will write the exam in English.

    Here are the main reasons that University of Ottawa graduates do not want to write the exam in French. They feel that the preparatory resources in French are inadequate and that the translation is poor. This has also been reported in the media. As a result, they are afraid of failing the exam. Failing the exam can result in job loss, as well as the additional cost of writing the exam again. Our second-year students are already expressing fears about the exam.

    As a school and as teachers, we are afraid of the negative impact this will have on minority francophone communities.

    Thank you.

    Thank you, Ms. Lalonde.

    You have the floor, Ms. Durocher-Hendriks.

    Hello. Thank you for listening to us.

    My name is Suzie Durochers-Hendriks and I am an assistant professor at the Edmundston campus of the Université de Moncton.

    In 2014, 100% of students at our campus passed the entry-into-practice exam. In 2015, the pass rate was 30%, even though the students had taken exactly the same training program.

    My colleague Mr. Godbout noted that our program has nonetheless been approved for seven years by the CASN and for five years by the NANB. In both cases, this is the maximum approval period possible.

    After taking their training entirely in French, our students have no choice but to purchase material in English, and that in an officially bilingual province.

    Several media reports partially blamed the Université de Moncton program for the francophones students' failing the NCLEX-RN exam. The number of students registered at the Edmundston campus has decreased since then. This year, we have just 12 new students. In the past, we typically had from 25 to 35 new students, and have had as many as 60.

    The francophones of northwestern New Brunswick are primarily unilingual and have very limited skills in English. Attending a French-language program and then having to prepare for an exam using resources that are in entirely English runs counter to everything we know about educational methods. Our students say they spend as much time trying to understand the English as they do the content of the practical questions.

    This threatens the French-language health services available to our patients, their families and our communities, in northwestern New Brunswick in particular. There is also an emotional impact on our students who cannot pass the exam.

    Thank you, Ms. Durocher-Hendriks.

    Ms. Larocque, you have the floor.

    Thank you.

    I am the director of Laurentian University's School of Nursing, which offers a bachelor of nursing entirely in French, as well as a program in English. The French-language program is supported by the Consortium national de formation en santé. We have the same admission criteria as for the English-language program, except for an additional requirement related to French since the students study in French. Our program has been approved for the maximum of seven years.

    In the past, the majority of our francophone students took the national exam in French. Some of our classes had a very high pass rate on their first try, up to 100%. We also noted that, in the past, those who took the test in English had a lower pass rate since they had studied in French for four years.

    In 2015, the majority of our students decided to take the exam in English. In 2016, 100% of students took the exam in English. In 2017, just as many students will take the exam in English. Among the reasons given are the fact that the preparatory resources for the NCLEX-RN exam are available in English only. It has also been pointed out that the translation of the exam is poor. The students said they got this information from other students who had taken the exam.

    The consequences of failing the exam have already been mentioned: it can lead to job loss and additional costs.

    We conducted a survey among this year's graduates. We asked those who took the French-language program whether, if they could go back in time, they would still choose the French-language program. Only 44% of them said yes, they would, because of the integrity of our program, because they can study in French and are proud of being bilingual, and because they can work in both languages. On the other hand, 28% of them said no, since there was no preparatory material in French for the NCLEX-RN exam and because they felt they really had no choice but to write the exam in English. The remaining 28% were undecided.

    If this trend continues, there will be a major impact on the number of francophone graduates and on the health services offered in French to francophone minorities. This also runs counter to the work of the Consortium national de formation en santé, which seeks to increase the number of francophone professionals who can offer services in French.

    Thank you very much, Ms. Larocque.

    Since we are running slightly late, the first round will be a five-minute round. I am going to be strict about respecting the allotted time so that as many people as possible get a chance to speak. The five-minute rounds will include both questions and answers.

    Mr. Généreux, you may begin.

    Thank you, Mr. Chair.

    I want to thank the witnesses.

    I will be brief.

    First of all, what does the acronym AIIC stand for?

    It is the Association des infirmières et infirmiers du Canada.

    Fine.

    There are no representatives from AIIC here today. There may be some in the second half of the meeting. If so, we will ask them why it is so difficult to obtain a proper translation of this online exam. Allow me to paraphrase the prime minister: it's 2017, after all. You say that you wanted to go from a written examen to an online exam. If that is indeed the reason why this exam was adopted — and I hope that the AIIC representatives will be able to confirm it — I can't believe that this is that complicated in 2017.

    What I am hearing today is beyond me. I can't get over it. I don't want to use qualifiers to describe my thoughts. One wonders if it isn't done on purpose in order to avoid having to provide services to francophones in their language throughout Canada, especially health care. This is beyond me, truly.

    I would have 50,000 questions to ask you, but I will limit myself to this one.

    When we were preparing for this meeting, we noticed that some people did not seem to see a problem concerning the success rate on the exam. Does the failure rate have to be 100% for people to understand that there is a problem?

    How is it possible that this can't be done in Canada?

    Aside from the francophone nurses of Quebec, only 4% of nurses elsewhere in Canada are francophones. That is part of the answer. We aren't considered numerous enough to justify the creation of commercial material. The market is not big enough.

    We know that health is a matter of provincial jurisdiction, like education. Mr. Godbout, I understand from your answer that the provinces cannot get together to pay for the training.

    What do you think, Ms. Durocher-Hendriks?

    Yes, that is precisely it. The many problems related to that exam, including the French, were mentioned as early as 2012.

    You say that there were multiple problems. What type of problems do you mean?

    The quality of the French mainly, but there are other problems. For instance, the content is inappropriate and inadequate, and the exam does not reflect Canadian practice.

    You say that the exam has not evolved.

    It is an American exam that was imposed on us.

    However, there are exams for Quebec nurses, are there not?

    Yes, there are.

    Can't we use the same ones in English Canada?

    It seems not.

    Why is that?

    I don't know.

    A Canadian is a Canadian. Can't we be treated equally? Why must there absolutely be different exams?

    If you continue to talk like that, you are going to become a liberal.

    Some hon. members: Oh, oh!

    When the draft exam came out, the problem of the lack of French resources was immediately apparent. We raised it. We asked where the translations were. We obtained them six months later. At that point we began to understand that there was a problem.

    No one expected that there would be so few resources at our disposal. I am talking about the preparatory material, which the anglophones received. The anglophones have access to everything, absolutely everything; they lack for nothing. Multiple companies busy themselves producing preparatory tools in English. But the francophones received nothing.

    Ms. Durocher-Hendriks, where do the preparatory tools used in Quebec to train nurses come from? Do they also come from the United States?

    No.

    Is it different because is it a francophone province?

    You have to understand that the regulation is provincial. The NCSBN promotes its exam a great deal, not only in Canada. It tries to sell it throughout the world. Up till now, only the other Canadian provinces have purchased the exam. I believe Australia may buy it as well. They attempted to sell the exam in Quebec. Quebec representatives went to the United States, they looked at the exam, and they decided not to buy it,because they felt that Quebec needed to control its own training.

    Would be possible to pool what is being done well in Canada? I know that the Quebec nursing program is well regarded. Could what is being done well in Quebec be used in the rest of Canada?

    I'd like to provide some important context.

    Please answer briefly.

    For historical and other reasons, Quebec withdrew from the Canadian organizations that regulate the profession. This left the other provinces together. That is a good part of the answer to your question.

    Are the standards the same? No, they are not. The possibility of using the same exam that is used in Quebec was already studied, but since the two health care systems are very different, a large part of the content would have to be adapted. I am not going to go into detail on that. That said, if Quebec were part of the equation, the market would justify the need, given the large number of francophone nurses.

    Quebec has its own health care system. Compared to the system in the rest of Canada, the health care system in Quebec is even more different than the American health care system, on which the NCLEX-RN exam that was imposed on us is based.

    Thank you, Mr. Godbout.

    Mr. Arseneault, you have the floor.

    Thank you, Mr. Chair.

    Ms. Baker, Ms. Lalonde, Mr. Godbout, Ms. Durocher-Hendriks and Ms. Larocque, thank you for your testimony.

    I come from New Brunswick and I am the member for Madawaska—Restigouche. I am quite familiar with the issue you are discussing. My wife was a graduate nurse at the University of Moncton in Ms. Wade's day. She worked at the Dr. Georges-L.-Dumont University Hospital Centre. In short, I am quite familiar with the dynamics.

    What you have just told us about in 15 minutes is a scandal, it is a huge barrier for francophones outside Quebec who want to study nursing. We know the situation well. I hear about it in my own village. Today we are hearing about it from professionals.

    I don't want to go into detail about the scandal because everything I've heard has given me a headache, but I would like to know one thing. To obtain your Bachelor of Science in Nursing, the last step is practical training, practical internships in the field. Based on the University of Moncton program, I can state that the Bachelor of Science in Nursing is the degree that includes the largest number of practical training field placements in the four years.

    Is it now a five-year program, or is it still four years long?

    It is a four-year program.

    It is one of the bachelor's programs that includes the largest number of practical training placements. The students do all of these practicums. During the last year, the last four months are entirely allocated to practical training. An experienced nurse is responsible for the nursing students, and he is able to confirm that the young man or the young woman has successfully completed his practical exam, his practical training. That student then receives his bachelor's degree. It seems to me that if there is an ultimate exam, it is that one.

    I would like to have a better understanding of the dynamics that exist between the professional corporations and you, the training institutions. I would like to know how we got to this point. Suddenly an exam arrives here from Mars, even though it has nothing to do with the university training you provide to your students; suddenly that exam has precedence over the practical training internship which confirms that the students are ready to work and care for patients. How did this happen?

    You are quite right. I would like to mention that when our students are recommended as ready to practice their profession, they have before that point succeeded in all of the steps of the training.

    The national exam confirms the student's studies, and allows greater mobility, so that he or she can practise in the other Canadian provinces. It's important. Such approval means that the training obtained in all of the universities is recognized.

    I should mention that the universities were absolutely not consulted prior to the introduction of this exam. They were put before a fait accompli.

    Who was it that did not consult you?

    I am referring to the regulatory organizations. We did not participate in anything...

    Who do these organizations report to, ultimately?

    Forgive me for rushing you, but I only have five minutes.

    The organizations are provincial, and since 2011, they are part of an organization known in English as the CCRNR. In French the acronym is CCORPI, but I forget what it stands for.

    It is the Conseil canadien des organismes de réglementation de la profession infirmière.

    It 's an organization that was formed suddenly, almost instantly, and claimed there was a need for change and a will to change the exam giving access to the profession.

    Could you repeat the name of that organization?

    In French it is the CCORPI. In English it's called the CCRNR, the Canadian Council of Registered Nurse Regulators.

    So New Brunswick is a member.

    Yes, it is.

    So that is the case for all of the provinces, including Ontario?

    Yes.

    Fine, that's good.

    It includes all of the provinces and territories with the exception of Quebec.

    I can understand Quebec's particular position.

    In other words, Mr. Godbout, Quebec saw the trap of this American translation, from a distance.

    Quebec's regulatory organization is a part of the organization we've just mentioned, but Quebec did not adopt that exam.

    I see.

    Long ago, Quebec abandoned the Canadian organizations that regulate nursing practice because of a lack of services in French.

    In 30 seconds, can you tell me if our training institutions, our universities, exerted pressure on these organizations? If so, what were these pressures, and what was the result?

    Our province is in a particular situation in the sense that our association represents all of our nurses, including the francophones. As you know, 33% of the population of our province is French speaking.

    You are talking about New Brunswick?

    Yes. Some of the members of our association are francophones. We have been there for them from the beginning. Because of this particular situation, the director general of the Nurses Association of New Brunswick, whom you will be meeting later, worked with us to find a solution. The issue is quite complex, but the fact remains that the success rate on the exam is not increasing. That is the problem and we have to do something. We are probably going to find a way soon to replace that exam, but that is where we are at for the moment.

    Thank you very much, Mr. Godbout.

    We will now hear from Mr. Choquette.

    Thank you, Mr. Chair.

    I thank all of you very much for being here today. I am glad you brought this problem to us. We have just finished our study of the new action plan, and health care in French is one of the sectors we need to invest in. When there are barriers that stand in the way of the provision of services in French, the federal government absolutely must be involved, because it plays a role in this action plan even if health is a provincial matter.

    I want to focus on your recommendations. The first is that the translation of that exam be adapted to our needs. Is that correct?

    No, not entirely. We recommend a bilingual Canadian exam, but not necessarily the one we had in the past. The Canadian Association of Schools of Nursing, which I represent, is ready to work with the regulatory organizations in order to come up with an exam that is truly bilingual.

    I understand that you want a bilingual Canadian exam. So that is your first recommendation.

    Yes.

    You feel that the American exam is useless because it is too far removed from our reality, is that correct?

    First, there is a lack of consistency between what is tested and what is taught. Second, we can already see that we will have an ongoing battle with the United States to obtain translations; up till now they have not complied with our request.

    I have understood the first recommendation well. However, whether we have a Canadian exam or an American one, we will still have the problem of the lack of resources in French, particularly preparatory materials.

    What is your recommendation to make more French-language resources available?

    We could have them translated.

    We can have them translated and adapted.

    I would like to mention that prior to this, with AIIC we had no problem regarding French-language resources.

    And why is there a problem now?

    It is because we gave permission to an entirely different company located outside of Canada to sell us its exam.

    I see.

    In the past we had resources available in both languages to prepare our students for the exam. Now there are no resources in French.

    If we brought back the Canadian bilingual exam, this would solve the problem of the lack of resources in French at the same time, correct?

    Yes.

    Well, that's brilliant.

    I have a question about the $450 amount that francophones have to pay in order to take the test. Do anglophones pay the same fee?

    Yes they do. It's a universal fee.

    Okay.

    In short, returning to the Canadian bilingual exam seems to be the clear, specific solution.

    You probably have already proposed this solution to the nurses' corporation. What was their answer?

    Which organization are you referring to?

    I mean the organization that chose to adopt the American exam. Which organization was it?

    In fact it was all of the professional corporations of each province that voted for the adoption of this type of exam to sanction access to the profession.

    I see.

    What was the reason for that decision? Did the American exam cost much less? Would it cost much more to have a Canadian exam?

    No.

    It is a computer adaptive exam. It's done on a computer. It's modern technology. The technology as such is good, but the problem is the content of the exam.

    Do we have the capacity to do the same thing in Canada?

    Some hon. members: Yes.

    I think we could do the same thing.

    Good, then that's clear.

    In addition, less Canadian money would be going to Americans.

    It could fuel the Canadian economy.

    Quite so.

    But in spite of everything, people tell us that there is nothing wrong with the American exam. They deny that there is any problem whatsoever with this exam.

    We are often told that the francophones are the ones who have a problem.

    So you are told that francophones are the issue.

    We are told that it is because the francophones aren't as good that they have a higher failure rate on the exam.

    Thank you very much.

    We will now hear from our next speaker, Paul Lefebvre, the member for Sudbury.

    Incidentally, I would like to thank Mr. Lefebvre for submitting the problem we are currently discussing to the committee, and for having suggested that you appear before us this morning.

    Mr. Lefebvre has the floor.

    Thank you, Mr. Chair.

    I want to continue discussing the recommendations.

    We understand the problem well. We have gotten to a point where many students who have taken their nursing studies in French no longer want to take the exam in French. The situation has snowballed, naturally. When the others notice that more and more French-speaking students are deciding to take their exam in English, they are less inclined to do their training in French.

    At Laurentian University and at the University of Moncton, how many students registered for the French-language nursing program over the past few years?

    Every year, in New Brunswick, about 100 to 125 students graduate, on average. There are 49 students in Bathurst, 80 in Moncton and about twenty in Edmundston.

    This year there were 22 students in Edmundston.

    Those are rounded figures. About 60% of these cohorts receive diplomas.

    You said that there were 125 students a year, is that correct?

    Yes, approximately.

    It's a four-year program, so that means there are more than 500 nursing students.

    Yes.

    That's correct.

    How many are there at Laurentian University?

    Approximately 200 students take the program in French. Between 30 and 50 students will graduate.

    How many are there at the University of Ottawa?

    At the University of Ottawa, we have between 70 and 90 graduates every year.

    On the whole, then, about a thousand students have chosen to do their studies in French.

    We need to consider the potential impact on access to French-language health care if the problem persists. My colleague Mr. Arseneault talked about it. I, too, have heard real stories about nurses who did not want to take the exam in French. We all know what happens next: they will no longer want to study in French.

    What does this mean for you, who are on the front lines?

    For Edmundston, which is a very francophone region, it would mean no longer having a nursing campus or training program. Since most of our students are not functionally bilingual, it isn't realistic to think that they would just go to another university. Of course, they could all go to Moncton, but enrolment in those programs is also limited. So it would have serious economic repercussions for our region and our campus.

    What's more, our region has a hospital and provides public health network services, so it is imperative that services be available in French. You can imagine the impact that a lack of nursing graduates who are certified would have on services. We are currently dealing with a significant shortage, and the situation is going to get worse over the next five years.

    I'd like to pick up on your recommendations. I think this is something that will be addressed by the next panel of witnesses we will be hearing from today: the impasse on this issue.

    I want to make sure I have this straight. You are recommending going back to the Canadian exam, the first exam, because the new exam and its translation have failed your faculties, your students, and Canada's francophone community, in your view.

    What is the biggest issue? What needs to be done to fix the situation?

    Basically, that's what it is.

    I'd like it repeated so that it is crystal clear.

    It's very important to mention that, even though more and more students are taking the exam in English, the pass rates aren't any better. It is in no way the be-all and end-all, just to be clear. We have the statistics. More francophone students are taking the exam in English, but their pass rates aren't any better. That isn't the way to solve their problem. It's the same situation. I have the statistics here: it's incredible.

    Even when they take the exam in English, the students aren't any more successful.

    It doesn't at all guarantee that they will pass. In our region, in northwest New Brunswick, students don't even have the option of taking the exam in English because they aren't sufficiently bilingual that it would boost their chances of passing.

    I know that, last summer, two of our students wrote the exam in English and passed, but they were native anglophones, so they were comfortable in English.

    We have a French program, but students have to rely on English resources to prepare for the French-language exam, which is very poorly translated. Given that it is not adapted to Canadian French, it does not take into account all of those important language distinctions. It's so bad that students tell us they don't even understand what the question is asking. They read the words but aren't sure what they are being asked. It's not at all familiar to them. What's more, they have studied the terminology in English, so it's extremely difficult for them right from the get-go. Passing isn't easy under those circumstances.

    Thank you.

    We will now travel to Nova Scotia, with Mr. Samson.

    You have three minutes, Mr. Samson.

    Thank you, Mr. Chair.

    Quickly, I will touch down in Nova Scotia.

    As an Université de Moncton graduate, I know the area and the issues well.

    My fellow members asked some very good questions, which I quite appreciated.

    How long will it take to fix the problem? You said the solution would be to go back to a bilingual national exam. Within what time frame could that be done? Could it be done overnight? Who decides whether or not to approve that?

    Are you asking how long it would take to develop an exam or to make the decision?

    How long would it take to make the decision to go back to a Canadian exam, on one hand, and who is in charge of making that decision, on the other?

    The regulating bodies make that decision.

    Does each province have to ask its regulating body?

    Yes, each province has to make the request.

    Is there a consensus on this issue among the provinces, and do they all wish to make the request?

    I don't believe so.

    How, then, will the provinces find a solution? Figuring out whether it's possible to do or not is well and good, but it's important to know who can fix the problem. Is it up to Canada's francophone minority communities to stand up and say that the current situation isn't working, that it's not acceptable, and that they want the Canadian exam restored?

    The problem really comes back to the provinces. It's not a national issue. If, for example, New Brunswick wanted to move forward with its own exam, that would solve things for francophones in that province.

    That would fix the problem in New Brunswick, but what about the other provinces? You can forget about Nova Scotia since it doesn't have a francophone institution. Let's talk about New Brunswick and Quebec, then. Students have to write their exam in English. That's shameful.

    Some hon. members: No, no, no.

    Quebec has its own exam.

    Yes, but there's Laurentian University.

    Laurentian University is in Sudbury, Ontario.

    Oh, my apologies.

    Which provinces are we talking about, then?

    In Quebec, the matter is settled. In New Brunswick, the problem remains. You have Ontario. Are there others?

    There's Manitoba.

    Add Manitoba to the list.

    Problems have also arisen in Alberta, at the University of Alberta's Saint-Jean campus.

    I see.

    Is there a desire among the francophone communities of those four provinces to call on their respective governments to restore the Canadian exam?

    Yes.

    Has the request been made?

    We made our dissatisfaction with the exam clear right from the beginning.

    Very well.

    You haven't received a response yet?

    No.

    What can we, in the federal government, do to help you?

    You can talk to our governments.

    Yes, okay.

    You can enforce the Official Languages Act.

    Yes, you can enforce the act and give francophones the same opportunities as anglophones.

    Very good.

    The lack of French-language preparatory materials is indeed shameful, just terrible.

    Have you spoken to the Government of New Brunswick?

    Yes.

    The process is under way.

    What's the answer?

    In fact, we did it previously as well, right from the beginning.

    It didn't work, then?

    No.

    We are in a crisis. Governments really need to make a decision.

    Thank you very much, Mr. Samson.

    Many thanks to all of you. You have given the Standing Committee on Official Languages some excellent insight. Thank you for being here and for providing your input. It was great.

    We will now take a quick break before we bring in our next panel.

    I now call the meeting to order, once again.

    We are delighted to have joining us two representatives from the College of Nurses of Ontario: Deborah Jones, director of communications; and Brent Knowles, director of analytics and research.

    Also with us today are two representatives of the Nurses Association of New Brunswick: Laurie Janes, executive director; and Jennifer Whitehead, manager of communications and government relations.

    Each organization will have about five minutes for its opening remarks, after which, we will move into questions and answers.

    Welcome to the committee.

    Who would like to start? The Ontario representatives will go first, then.

    Mr. Knowles, we're listening to you.

    Good afternoon. Thank you for the invitation to share on this important issue.

    The mandate of the College of Nurses is the regulation of nursing in the public interest. We are in a unique position nationally, as we are currently the only nursing regulator responsible for the regulation of all nurses in the province, namely, practical nurses, registered nurses, and nurse practitioners.

    A component of this mandate is establishing entry requirements, including approving nursing programs in the province and approving an entry exam. In 2015, the college, along with other registered nurse regulators, excluding Quebec, approved the NCLEX-RN as the entry to practice exam for RNs.

    I should mention that the exam tests whether a candidate has the basic knowledge, skills, and judgment needed to provide safe nursing care to the public. Examples of this include how you assess the need for pain management or how you perform a comprehensive health assessment. Again, it's not an American or Canadian exam; it's a nursing regulation exam.

    The NCLEX is also a different type of exam. It's a computerized adaptive test. Research indicates that, when the format and delivery methods for an exam change, you would expect to see a temporary decrease in the performance of test takers.

    We provided you with data to reference during the presentation.

    If you look at table 1 in the handout, it shows the first attempt pass rate on the NCLEX for graduates from Ontario's registered nursing programs. In 2015, you will notice that, when we introduced the NCLEX, the first attempt pass rate dropped to 69.4% from 84.7% in 2014 with the previous exam. For 2016, the pass rate was 80.3%, returning it to the range of pass rates we had previously observed, which really showed us that the phenomenon we expected to happen through research occurred.

    However, when we look at the language in which the exam was taken, we see a significant difference in the pass rates for graduates who wrote in English versus French. In 2015, 34.8% of writers who attempted the NCLEX exam in French passed. This increased slightly to 37.5% in 2016. This pass rate concerns us and the issue seems to be confounded by a number of other factors. One is that historically, we have seen lower first attempt pass rates for graduates writing in French. As you see, from 2011 to 2014 with the previous entry exam, there was a significant difference in pass rates in three of those four years.

    We are also seeing a lower percentage of graduates from our French programs writing in French. Prior to 2015, the majority of graduates from French programs wrote the entry exam in French. However, since 2015, the majority have chosen to write it in English. This makes it difficult to get a clear picture of how graduates of French programs perform on the exam.

    One of the things we looked at was how graduates of French programs were performing overall on the NCLEX exam. Table 2 in the handout provides this information. It highlights that in 2015, the average first attempt pass rate for French programs was lower than the average for all programs. However, in 2016, the average first attempt pass rate for graduates of French programs was about 78.3%, which is virtually the same as all programs.

    The other interesting thing we've noticed is that the first attempt pass rate for those graduates of French programs who take the exam in English is higher than the overall Ontario pass rate.

    We also looked at rates of registration for graduates from French programs in comparison to graduates of English programs. We saw no difference in the rates of registration or rates of entry to practice for these groups. This demonstrates that in the short term there has been no impact on the availability of French-speaking nurses to the health care system in Ontario since the introduction of the NCLEX exam.

    To confirm our confidence in the exam translation, we conducted an extensive review of the exam provider's process. The results reaffirmed the rigour of the translation. In addition, an independent review of the French translation was conducted by the translation bureau of Service New Brunswick and found, "The content of the message is accurately translated." The reviewer's overall conclusion was "the quality of the French translation of the exam I reviewed was satisfactory given that there are no major errors in meaning or major language errors, and the level of French was appropriate."

    However, having said that, we continue to be concerned with the low pass rates for candidates who choose to write in French. This year we will be meeting with educators in our French education programs to discuss this issue and to gain greater insight. In addition, we will be conducting research with exam candidates who graduate from a French program to gain a better understanding of their experience with the exam and what influences their choice of exam language. Some of the factors we plan to explore include the mix of English and French courses in the program, the availability of French language clinical placements in Ontario, and the language skills of the cohort.

    As I have already mentioned, the college continues to look at the low pass rates of candidates who choose to take the exam in French. I want to emphasize that this has not resulted in a decrease in the availability of French-speaking nurses to the health system in Ontario, and the college remains committed to ensuring that the public in Ontario continues to have access to nursing services in both official languages.

    Thank you.

    Thank you, Mr. Knowles.

    We'll now hear Laurie Janes. Go ahead.

    Thank you for inviting us today, honourable Mr. Chairperson and committee members. My name is Laurie Janes. I represent the Nurses Association of New Brunswick, NANB. We are the regulators of nursing in New Brunswick as well as an association.

    We're here today to discuss the continued delivery of safe, competent nursing in New Brunswick and the introduction of a new exam and the impact of that exam in our province.

    New Brunswick is a small, rural province with a population of only 750,000. Approximately 30% of New Brunswick residents are francophone. We have two health regions. One delivers services primarily in English, the other primarily in French. Our French health region is the only health system offering all services solely in French outside of Quebec. Many residents served by this health authority speak only the French language.

    The Nurses Association mandate is to regulate nurses to provide safe, competent, and ethical care in the interest of our public. We believe that safety is optimized when nurses can provide services in the patient's language of choice. In fact, in New Brunswick the language of choice is a right; we are the only bilingual province in Canada. All public service is mandated to be bilingual, that is, to be delivered in either French or English, as the patients and their families wish.

    In 2012, all jurisdictions in Canada signed a contract for a new entry-to-practice exam, the results of which would determine whether our nursing graduates could become licensed to work as registered nurses. Representing the sole bilingual province, NANB requested that French-language resources be supported during an RFP process for the new exam. When the exam provider was named, there were no French resources included in the proposed contract.

    In 2015, the first year the exam was written in Canada, the exam provider published a new online resource for nursing students. We were advised of this by a student studying for the new exam. It was published in English only. Later, in September 2015, NANB was advised that only 32% of the francophone nursing graduating class had passed the exam. The 2016 results were not much improved.

    There was a resource provided through the previous exam for French-language students. There are some resources provided now. We don't believe resources or translation is the issue.

    The NCLEX exam, as our new exam is named, has been written in the United States for 20 years. There is a host of published evidence clearly indicating that non-English and minority groups do not do as well as students who have English as their primary language. Further literature informs us that these same students are often held back from graduating or drop out because of progression policies implemented by nursing programs that must meet performance targets in order to receive continued funding.

    New Brunswick's population is a small one to draw on for our French-speaking nurses. Because of this, French students may meet, but may not succeed, required university admission criteria. Additionally, they must concurrently study language while also studying the requirements of a nursing degree. For some graduates, this translates into lower academic achievement than is required to succeed in passing NCLEX, and this is the experience faced by non-English-speaking and minority groups in the United States.

    New Brunswick is hearing anecdotal information that in some areas of Canada, our indigenous nursing graduates are also having difficulty in passing NCLEX. This is a matter of concern in a country that welcomes diversity.

    We have explored, and explored intensively, the opportunity that Quebec might afford us to partner with them. However, l’Ordre des infirmières et infirmiers du Québec is currently in a transition in their exam. They're moving to a computer-based exam and are looking at a different blueprint, as it's called, for their exam.

    In French?

    Yes.

    We felt that they would be a good fit because the exam is offered in English and French and the resources are offered in English and French. However, there are some legislative barriers, and because they're in transition, they're not able to assist us at this time. Perhaps there is some opportunity in the future, but not for the next three years.

    The impact of the results of the exam is serious in New Brunswick. Many of our French graduates have had to do multiple writings to attain a passing grade. That places a significant economic burden on many of them. There are few French-language resources available that compare to those commercially produced by the current exam provider.

    Our French health region is concerned about a future French language nursing force. We know that this year there are 12 nursing graduates who, unless they pass the exam by the end of this month, will no longer be able to contribute to nursing care in the northern part of our province. We are very concerned.

    The Nurses Association of New Brunswick believes in measuring nursing graduate knowledge and skills to assure safe, competent, and ethical care. This is our mandate. However, we are troubled by the impact of this new exam in Canada, especially in New Brunswick.

    Therefore, in conclusion, NANB has three requests for the committee.

    First, we request that the committee offer recommendation and support for immediate availability of French-language study resources by the exam provider. We have been making this request for two years.

    You have?

    Yes.

    We ask that a Canadian nursing group be struck immediately to complete a thorough evaluation of the impact of the implementation of NCLEX in Canada, especially for graduates whose primary language is not English and other minority groups.

    We ask that the committee recommend that the results of the above-mentioned evaluation inform the feasibility of continuing to use this exam as the requirement to entry to nursing practice in Canada.

    Thank you.

    Thank you very much, Ms. Janes.

    I want to let the committee members and witnesses know that each member will have four minutes for questions and answers, and I will be strictly enforcing that time limit. The four-minute block covers both questions and answers.

    You will start us off, Mrs. Boucher.

    Good afternoon.

    I'd like to thank the witnesses for being with us today.

    There are no words to express how deeply shocked I was to learn that every provincial professional association—other than Quebec's—came to an agreement to adopt an American exam that was developed in English. This is the year 2017. Canada has a francophone population as well. It's rather insulting to us, francophones, to see how unconcerned the provinces are about the fact that francophone students don't even have access to study materials in their language, while anglophone students have all the resources they need. That's unacceptable. This is 2017, and all of us here, on all sides, are fighting to make Canadians understand that we have two official languages. What you are describing is unthinkable.

    I would like to know whether you have francophones in your associations who know how difficult it is to receive service in French. Indeed, it was the professional associations who agreed amongst themselves to adopt the American exam. Did you consult people or organizations other than professional associations? Why did you decide not to keep the Canadian exam? It was working quite well before, but you decided to go with an American exam. I would like to know why.

    Why did you not demand that French-language resources be made available?

    Who would like to answer?

    I can start speaking to that.

    First of all, this goes back a number of years. I think one of the largest misconceptions, and you continually hear it being said today, is that this is an American exam. It's not an American exam. I think there were certain requirements we had actually requested when we went to RFP, which was an open RFP process which was bid on by exam providers in a number of jurisdictions, including Canada. One of those requirements was teaching an exam that would test entry-to-nursing competencies, not cultural differences, because we fully understand that, even in the U.S., there are very specific cultural differences between Florida, California, New York, and Michigan. The exam can't be an exam that actually—

    Yes, but they speak English.

    —looks at the cultural differences even within Canada. When we looked at the exam, one of the things we looked at was to have that be in place.

    Second, the exam was not purchased and then implemented without any review process; in fact, Canadians are now part of the process for developing every question now part of the exam, both francophone and anglophone nurses. With more time, we can provide a briefing around this, how the translation process occurs, but that's involved as well.

    One of the other ones that's a really difficult one to speak to is around preparatory material. The position of the College of Nurses of Ontario is that the programs would prepare the students for success in the entry exam. Prep materials support that, obviously, and we understand and do acknowledge that there is a lack of preparatory materials in French.

    Yet you have material in English.

    They're only in English, but again, it's not the role of the regulator to provide preparatory materials for students in preparing to write the regulatory exams.

    I realize that, but we are francophones.

    Your time is up, Mrs. Boucher.

    I want to tell the witness this: preparatory materials are available in English, but we are francophones.

    Thank you very much, Mrs. Boucher.

    It is now over to you, Mr. Lefebvre.

    Thank you, Mr. Chair.

    Thank you for coming to this discussion with us.

    Clearly, the reason you're here, as you may know, is that the government finances, subsidizes, some of the programs to offer education for health in French across Canada.

    We heard of this issue, and you had heard of it before you arrived. It's a scathing report. They came to us and said that this is an emerging situation that is very, very concerning.

    Unfortunately, I'm hearing two different things. Mr. Knowles, you're telling us, yes, it's an issue and you're looking at it and will study it, and it's not that pressing for you. Ms. Janes says her group has a recommendation and is asking for some help. Those are the two messages that I'm hearing.

    Mr. Knowles, I think when you came in you told us that people will still have access to nurses who speak French. They may be trained, basically, but they might not write their exam. That's kind of what you're telling us.

    It's kind of difficult for us here and certainly for me, as you can see, I speak English. I'm a francophone, but I can work in English as well. That being said, for people who require services in French by francophones, it's not the same thing. I'm a French lawyer. If I had not studied in French, I would not have been able to provide the proper services in French and I would probably work in English most of the time. So when you come here and say that regardless, the francophones can still provide services in French, that is very difficult for us to accept.

    You heard the recommendations from Ms. Janes. Is there a possibility that Ontario...? I know you're saying that you want to further study this, but from what you've heard today and our concerns here, financing these institutions and saying, “Well, down the road who knows where we will be”, what are your comments? Is there anything from what you've heard today on how we can move forward and improve the current situation and crisis we are facing?

    I might as well start by saying that I hope it didn't feel as if we've underplayed or not taken this issue seriously. We do, but I feel that we are in a unique position in Ontario. I think Ms. Janes actually highlighted that there are differences even in the way the program is delivered in Ontario, and it's one of the things that we have to look at, because we have to have a greater understanding of the very nature of our programs in Ontario to understand the impacts that may influence why the students are performing the way they do.

    I feel one of the concerns is that we need to look at this beyond just the factor that a difference in pass rate must mean there's an issue with the exam. We're suggesting that there could be other factors at play before we move to stepping away and saying the exam itself is the only issue. That's why we want to actually have some time to take a look at how students are performing, to talk to students, and to then speak with our educational partners as well to see what some of the issues are that are at work here.

    Sir, with all due respect, that didn't happen in the first place. You didn't have those conversations with your institutions, certainly the francophone ones, because we heard that clearly before, but I'm happy that you're saying we should have that conversation, because that's where it starts.

    If l’Ordre des infirmières et infirmiers de l’Ontario would have that conversation with the educators, I think that's a great place to start.

    The other thing that I think I want to share with the committee is the role of the regulator and the role of the educational institution. As you know, the role of the regulator is to determine the entry exam. It would be something of a conflict of interest to have the education community involved in certain ways with how an exam would work, that is, a high-stake exam for entry into practice. I fully understand that we want to have communications and we want to involve our colleagues, but it's difficult to have the educational institutions determining the appropriateness of an exam for entry.

    That being said, there are important stakeholders involved in the conversation that we're having, and there are also important stakeholders in terms of helping us to understand the impact of the entry exam on their student population.

    Thank you, Mr. Knowles.

    We'll now go to François Choquette.

    Thank you, Mr. Chair.

    The Standing Committee on Official Languages is already quite concerned about the health care services available in minority language communities across the country, meaning French-language health care outside Quebec and English-language health care within Quebec. And now, we are learning about a problem that may further undermine the availability of French-language services all over the country.

    We realize that Ontario has a problem, but it isn't the only one. This affects all the other provinces, as well. Ontario isn't alone in offering nursing programs in French. My understanding is that four or five universities provide the training.

    Today, we heard from witnesses representing a number of provinces where nursing programs are offered in French. They had just one recommendation for the committee. I would've thought they would come to us with two, three, four, or five recommendations, but that wasn't the case. They recommended only one thing: that the bilingual Canadian exam be restored. The witnesses told us that following through on that particular recommendation would fix all the other issues, including the lack of French-language preparatory materials.

    The Standing Committee on Official Languages is very worried about this situation. We just released a report on the new official languages action plan, and health plays a central role. The government in power will certainly want to make sure that health services in the minority language are not less accessible but, just the opposite, more accessible.

    Given what I've just told you, would you reconsider your decision to use an American exam, in favour of going back to a bilingual Canadian exam? We were told that it could be done, that the science existed, and that we had the skills to do it.

    I'd like to hear where each of you stand on that.

    You each have a minute.

    Ms. Janes, you can start.

    Thank you, Monsieur Choquette.

    Yes, in fact, New Brunswick has been working with a variety of stakeholders, including our government, for the last year and a half now. We have advised the CCRNR, the Canadian Council of Registered Nurse Regulators, that because of our situation, we may have to explore, and now are exploring, alternatives to the NCLEX.

    I want to assure Madame Boucher that the exam is currently offered in both French and English. They can write it, but there are limited resources.

    It is not so much the translation that concerns us, or the resources; it is the U.S. experience for the last 20 years. We have researched, and there is a large number of research articles and documents that inform us that in the U.S., where Spanish is prevalent, the Spanish students have the same experience that our French students are having.

    This is very concerning, as are reports coming from northern areas of our province, where our indigenous people are also having the same experience in terms of failure rates.

    Thank you, Ms. Janes.

    Mr. Knowles.

    One thing I think we need to look at, and we've shared it in the data we've shown you, is that this discussion centres around a Canadian exam. I would draw your attention to the data we provided. In fact previously the exam provider was a Canadian organization, and the differences we're seeing were also in place then.

    That is not to say that therefore this is not a serious issue or not an issue we need to look into, but the previous examination provider that we had was a Canadian organization, and we saw a difference in pass rates: a lower pass rate for French writers of the exam versus English writers. Our current practical nursing exam is still provided by a Canadian organization, and we see significant differences there, too, except for this year, when for a very different reason that changed.

    Talking about the need for moving to a Canadian provider I think goes back to understanding what the exam tests. The exam is not a test of the Canadian health care system; it is a test of nursing competencies, and nursing competencies that are stripped of any cultural differences at all. That's really the heart of the exam. If we changed the exam, we would still be moving to an exam that would be testing that.

    Thank you, Mr. Knowles.

    We go now to René Arseneault.

    Thank you, Mr. Chair.

    Thank you for your input, Mr. Knowles.

    Ms. Janes, thank you for giving us insight into New Brunswick's position.

    Mr. Knowles, forgive me, but your naive approach to this issue baffles me. I'm going to share a little anecdote with you.

    I'm a lawyer by profession. I had occasion to practise law with some colleagues from France. Even though we would be discussing the same document with the same legal objective in mind in the same language, we did not interpret the content the same way in arriving at the same goal. And yet, I speak French very well, and I did all my training in French, as did my counterparts from France. Despite that, we had to write things differently in order to achieve the same thing.

    Can you appreciate that? Do you know what I mean? You realize that I am talking about nuances.

    You keep saying that the exam is not an American exam, strictly speaking. However, that isn't what the committee heard from all the witnesses representing the teaching institutions that train Canada's nurses. They told us that it was an American exam, regardless of what you say.

    The language of the United States is, of course, English. I want to come back, though, to my story of two lawyers who speak French but come from different countries.

    Can you see how an exam written in American English might not accurately reflect the terminology used in Canadian English or Canadian French in the field of nursing? Do you see how that could be possible? I don't have much time left, so a simple yes or no will do.

    What I can say is that the individuals who have said that they have reviewed the exam have in fact not done so. The exam, because of the high stakes nature—

    Sorry, Mr. Knowles, but my question is simple.

    Can you conceive that it's possible for the English content of a nursing exam from the United States to say exactly the same thing in Canadian English or Canadian French, but not be written in the same manner, without the same expressions or same words? Is that possible in your mind, to conceive in the mind of the Ontario college, yes or no?

    It's not a yes or no question you're asking. What I'm suggesting is that it's possible, unless we have a conversation on the process it's undertaken. When we have Canadians involved in all steps of the process, including the creation of the question through the translation—

    Then how come there was no consultation with the institutions, with the universities? How come?

    I think—

    This is important. How come?

    Consultation takes various different forms. I would suggest that if you were writing an exam that is going to be testing concepts that were taught in a program, it may be problematic to have the individuals who were involved in teaching the program setting the test.

    Mr. Knowles, in the name of the order that you are presenting for today, how come there was no consultation with the French universities? For example—

    By consultation you mean....

    About the exam, the content, you said it's a Canadian product—

    The content of the exam is—now we can have that discussion as well, too—being taught through the curriculum of the programs. We've done a full study of that as well, to ensure that....

    Ontario also sets the entry requirements, so we ensure that the entry requirements of the programs and the curriculum cover the content that will be tested in the exam. Therefore, the—

    Again, my question is how come we heard people here, professionals, nurses, say that they had never been consulted, even in New Brunswick.

    Again by consultation—

    It's the content of this exam that you need, to practise nursing.

    The content of the exam is taught in the programs that we approve and that we review on an ongoing basis, to ensure that the content of the program is something that is being tested by the exam. That's part of our overall mandate, to ensure that all these components work together.

    Do I have 10 seconds to conclude?

    No, Mr. Arseneault. We are out of time.

    That was the last word.

    I would like to thank you very much, Ms. Jones, Mr. Knowles, Ms. Janes, and Ms. Whitehead, for your presentations. It's going to help the committee to assess the situation. On behalf of the committee, thank you again.

    The committee is adjourned.