Introduction

In 2015, the provincial and territorial regulatory bodies responsible for the nursing profession in Canada, except the one for Quebec, adopted the National Council Licensure Examination, or NCLEX‑RN.[1] The NCLEX‑RN is an exam that registered nurses must pass in order to practice nursing in Canada (outside of Quebec). The main topics of the exam are pain management, the administration of medication, basic care and comfort, and safety and infection control.

The NCLEX-RN was developed by the National Council of State Boards of Nursing (NCSBN), an American organization. It “replaced the bilingual Canadian exam, which was created a long time ago by the Canadian Nurses Association.”[2] The provinces and territories chose the NCLEX-RN because it was available in electronic form.[3]

In May 2017, the House of Commons Standing Committee on Official Languages (the Committee) became aware that nursing graduates who choose to take the NCLEX-RN in French have a much higher rate of failure than those who take it in English. It should be noted that only students, representatives of post-secondary institutions and nurses from Ontario and New Brunswick appeared before the Committee.

French-language training in nursing is an important link in the chain of French-language health care. Indeed, the capacity of minority francophone and bilingual post-secondary institutions to train nurses who can provide services in French is one of the factors that influence the vitality of francophone minority communities.

Although regulating nursing falls to the provinces and territories, this issue is of interest to the Committee. The Committee plays an oversight role in advancing the official languages and enhancing the vitality of official language minority communities, as well as in all issues that could help or hinder federal institutions in achieving their official language objectives.

Note that the Action Plan for Official Languages – 2018–2023: Investing in Our Future, announced by the Honourable Mélanie Joly, then-Minister of Canadian Heritage, on 28 March 2018, provides for a total health care investment of $191.2 million over five years. Health Canada also supports French-language nurses training through the Consortium national de formation en santé (CNFS). In addition, federal funding has already been provided to create a French study resource to support registered nurses who choose to take the NCLEX-RN in French (this issue will be discussed in section 4 of this report).

1. How the NCLEX-RN was selected

The development and selection of the NCLEX-RN were part of a request for proposals launched in 2011 by the Canadian Council of Registered Nurse Regulators. According to Mr. Brent Knowles, Director of Analytics and Research, at the College of Nurses of Ontario (CNO), it was “an open RFP process which was bid on by exam providers in a number of jurisdictions, including Canada.”[4]

It is worth noting that “the universities were absolutely not consulted prior to the introduction of this exam.”[5] According to Mr. Knowles, this is normal, as 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[s] exam for entry into practice.”[6]

2. The French translation of the NCLEX-RN and the lack of French preparatory materials

The Canadian Nursing Students’ Association (CNSA) and the francophone and bilingual post-secondary institutions that offer French-language nursing programs are concerned about the low success rate among francophones and are calling for corrective action.[7] CNSA publicly blamed “the low pass rate among French students on translation errors and a lack of French preparatory materials.”[8]

2.1. The quality of the translation

In response to the allegations that the translation of the NCLEX-RN was poorly done, the Nurses Association of New Brunswick (NANB), the Government of New Brunswick and the exam provider “authorized a third-party translation review.”[9] This review was carried out in February 2016 by the Director of Service New Brunswick’s Translation Bureau. After reviewing 60 questions from the NCLEX-RN, the evaluator concluded that, “overall, the quality of the French translation of the exam … was satisfactory given that there are no major errors in meaning or major language errors, and the level of French was appropriate.”[10]

In 2016, the Office of the Commissioner of Official Languages for New Brunswick carried out an investigation after two complaints were filed about the NCLEX-RN. The complainants alleged that they were “placed at a disadvantage when they chose to use French to satisfy the requirements to be able to work in the nursing profession.”[11] They cited problems with the French translation and a lack of French resources to prepare for the exam.[12]

The Commissioner of Official Languages for New Brunswick, Ms. Katherine d’Entremont, examined whether NANB had contravened subsection 41.1(3) of New Brunswick’s Official Languages Act when it selected the NCLEX-RN. That subsection of the Act reads as follows: “No person shall be placed at a disadvantage by reason of exercising his or her right to choose an official language in which to fulfil requirements imposed by a professional association.”[13]

The Commissioner subsequently ordered a new independent evaluation of the French version of the exam to assess the quality of the French translation. This time, a certified translator from Service New Brunswick’s Translation Bureau reviewed a sample of 250 questions. The evaluation was carried out on 27 March 2018, two years after the initial review. The certified translator concluded that “[o]verall, the French translation of the NCLEX-RN exam questionnaires is of good quality. … The few weaknesses and errors detected here and there should not interfere with the understanding of the questions, since most of the time the key elements are presented clearly enough for there not to be any ambiguity.”[14]

While the evaluator noted that some questions contained errors, he had “the clear impression that the weaknesses he found are the result of tampering with the questionnaires after the translation stage, that is, the version provided by the translator was changed by individuals with an insufficient knowledge of French to do this kind of work.”[15]

As a result, Commissioner d’Entremont recommended to NANB that, “[r]egardless of the entry to practice exam chosen by the Association, … the translation of the exam and any subsequent revision be done by a certified translator.”[16]

Dr. Cynthia Baker, Executive Director of the Canadian Association of Schools of Nursing (CASN), pointed out that the NCLEX-RN is updated regularly. She explained that it is “not just a question of improving the existing translation, then, but of ensuring that there's a methodology going forward that ensures an adequate, equitable translation. An adaptation is more expensive, I understand, than a basic translation, but it is what is used in Canada.”[17] On this issue, the CASN reportedly heard “from federal translators and from psychometricians in Canada that adaptation is a rigorous, more specialized process, and it's recommended … for high-stakes exams in both languages, to ensure equity.”[18]

2.2. The lack of French preparatory materials

In her investigation report on the NCLEX-RN, the Commissioner of Official Languages for New Brunswick reached the following conclusion regarding the availability of French-language preparatory materials for the NCLEX-RN:

There is indeed a significant gap in the exam preparation resources available to one linguistic community compared to the other. Whereas there is only one French-language question bank tool, with no simulation exam and a limited number of practice questions, there is a vast array of high quality English-language exam simulations that are commercially available. Therefore, Francophone candidates are not on a level playing field compared to their Anglophone counterparts.[19]

Because of the lack of French preparatory materials, Commissioner d’Entremont concluded that NANB contravened New Brunswick’s Official Languages Act by selecting the NCLEX-RN. As a result, the Commissioner recommended that NANB “take the necessary actions so that requirements to enter the nursing profession in New Brunswick fully respect subsection 41.1(3) of the Official Languages Act of New Brunswick”[20] and that it report to the Office of the Commissioner “no later than September 4, 2018.”[21]

The Commissioner recognized that NANB has no control over the study materials in English. However, she wrote that NANB “cannot ignore the existence of these resources as well as their availability.”[22]

Dr. Baker explained that the lack of French preparatory materials is due to market forces: “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.”[23] Mr. Pierre Godbout, Director of the School of Nursing at the Université de Moncton, added the following: “Aside from the francophone nurses of Quebec, only 4% of nurses elsewhere in Canada are francophones. … We aren’t considered numerous enough to justify the creation of commercial material. The market is not big enough.”[24]

Ms. Suzie Durocher‑Hendriks, Assistant Professor at the Université de Moncton’s School of Nursing, Edmundston Campus, said the lack of preparatory materials puts students and their professors in an untenable position:

Attending a French-language program and then having to prepare for an exam using resources that are entirely in 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.[25]

NANB recognized that there are “few French-language resources available that compare to those commercially produced by the current exam provider.”[26] The association also reported that it attempted to obtain French resources:

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.[27]

Since then, NANB and CNO – which also acknowledges the lack of French preparatory materials – have taken a series of measures to improve the success rate for francophones.[28] According to the information they shared with the Committee, one of those measures was to enter into a dialogue with francophone and bilingual post-secondary institutions.

NANB and CNO reported that NCSBN has launched two initiatives to improve the availability of French preparatory materials. First, it has struck a committee to develop and standardize over the long term the French terminology used in the exam.[29] This committee consists of Canadian francophone and bilingual educators and regulators. Second, NCSBN has developed a French practice exam. This tool should be available in both official languages in June 2018.[30]

3. How the francophone success rate affects French-language training programs for nurses and the provision of health care services in French in francophone minority communities

The low success rate for francophones who take the NCLEX-RN appears to have a negative impact on French training programs for nurses. To start with, students are choosing not to take the exam in French.[31] As Dr. Baker pointed out, “Graduates feel … that they have no other choice than to write the exam in English.”[32]

At the University of Ottawa in 2016, “just 15.8% of … students wrote the exam in French. … In 2017, it is expected that 64% of students will write the exam in English.”[33] In the past, the majority of francophone students at Laurentian University wrote the national entry-into-practice exam in French. Ms. Sylvie Larocque, Director of the School of Nursing at Laurentian University, said that “some of our classes had a very high pass rate on their first try, up to 100%. … 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.”[34]

In Ontario, it appears as though francophone students who take the exam in English do fairly well.[35] However, in New Brunswick, taking the exam in English does not improve graduates’ performance. Mr. Godbout offered the following explanation:

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.[36]

Moreover, some francophones regret choosing to study nursing in French. Dr. Baker reported that some students “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.”[37]

Laurentian University surveyed its students to determine whether they would choose to enrol in a French-language program if they could start over:

Only 44% of them said yes, they would. … 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.[38]

The Université de Moncton has seen a significant drop in enrolment because of the failure rate for francophone students. Ms. Durocher‑Hendriks gave the following explanation: “Several media reports partially blamed the Université de Moncton program for the francophone students’ failing the NCLEX-RN exam.”[39] As a result, the “number of students registered at the Edmundston campus has decreased since then. This year [2017], 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.”[40]

Like other stakeholders, Dr. Baker said the situation could have major consequences for the provision of health care services in French in francophone minority communities.

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.[41]

In its testimony, NANB argued that the poor NCLEX-RN success rate for francophones is a threat to the provision of nursing services in French in New Brunswick:

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.[42]

Since then, NANB has clarified its position. The association explained that registered nurses earn a temporary licence when they successfully complete their studies. They can therefore practise nursing for two years while they attempt to pass the NCLEX-RN. Since most of them pass the exam before this two-year period expires, there is little or no impact on the provision of services in French.

As for CNO, it stated that the implementation of the NCLEX-RN “has not resulted in a decrease in the availability of French-speaking nurses to the health system in Ontario.”[43]

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.[44]

The Committee notes the lack of recent studies on the health of francophone minority communities, and even fewer on supply and demand for nursing services in French in Canada. During a fact-finding trip to the Yukon in September 2018, the Committee learned that joint national-provincial/territorial surveys rarely include the linguistic variables needed to obtain data on the health of the official language minority. When such data are collected, it appears that smaller communities, particularly those in the territories, are at a disadvantage: instead of presenting the unique profile of each community, researchers tend to group them into regions because of the small numbers. Yet it is essential that all communities, regardless of their size, have access to hard data so that they can appeal to government authorities.

4. The Consortium national de formation en santé

The post-secondary institutions that offer French nursing training programs viewed the decision to adopt the NCLEX-RN as inconsistent with Health Canada’s efforts and investments to improve health outcomes in francophone minority communities.[45]

At the federal level, the Official Language Community Development Bureau (OLCDB) is the part of Health Canada responsible for coordinating the implementation of section 41 of the federal Official Languages Act (Part VII). The OLCDB is also responsible for managing the Official Languages Health Contribution Program. This program has three main components:

• Integrating Health Professionals in [official language minority communities] OLMCs – which, by working with post-secondary institutions, aims to increase the supply of bilingual health professionals available to serve OLMCs;
• Strengthening Local Health Networking Capacity – 36 local and regional networks which operate as community-based entities to build capacity to [e]ffect change in the health care system with a view to improving access to health services within OLMCs; and
• Health Services Access and Retention Projects – which promotes, through specific initiatives, better integration of and improved access to health services for OLMCs.[46]

The OLCDB works with organizations such as the Société santé en français and the CNFS to achieve its objectives in supporting francophone minority communities.

Five CNFS member institutions are involved in nursing training: the University of Ottawa, the Université de Moncton, Laurentian University, the Université de Saint-Boniface and the Campus Saint-Jean in Alberta. For the past five years, these five institutions have together received about $10.6 million in annual funding provided by the federal government, for an overall total of $53.2 million.

For over two years, the CNFS has been working with the institutions in its network that are affected by the NCLEX-RN crisis to develop a French-language preparatory tool for the exam. Together, they created a bank of 250 questions, divided into eight training modules. This bank of questions was made available to students, graduates and professors of nursing programs supported by the CNFS. Laurentian University manages the tool.

To date, the CNFS has provided $225,741 in funding for the project ($115,000 in 2015‑2016 and $110,741 in 2016‑2017).

The report of the Commissioner of Official Languages for New Brunswick states that the Laurentian University materials “fall far short … of the commercial products available in English.”[47] Staff and students at the Université de Moncton reportedly said the following:

[T]he depth and quality of the [Laurentian] questions fall far below what is offered in the commercial resources, and the students do not feel the [Laurentian] preparation materials properly prepare them for the NCLEX-RN. As such, the [Laurentian] tools, despite being available for free, appear to be hardly used by Université de Moncton nursing students and graduates.[48]

5. Recommandations and conclusion

It is clear that the decision to adopt the NCLEX-RN without coordinating its translation with certified Canadian translators or developing French study resources of equal quality to those available in English did significant harm to minority francophone registered nurses.

In light of the above, the Committee recommends:

Recommendation 1

That the federal Minister of Health:

a)      with her provincial and territorial counterparts commit to finding solutions to the active offer of health services in both official languages and to make professional bodies aware of the needs of official language minority communities in terms of access to health professionals, including nurses able to offer services in the minority language.

b)     ensure that bilateral agreements on health include enforceable language clauses that, through the transfer of federal funds, meet OLMC needs.

Access to recent hard data on the health of francophone minority communities is essential to improve the availability of health services in the language of one’s choice. Therefore, the Committee recommends:

Recommendation 2

That Health Canada require that the studies conducted by the Canadian Institute for Health Information include linguistic variables in order to collect solid data on the health of official language minority communities and ensure that sampling reflects these communities.

The Committee believes that, if the regulatory bodies responsible for the nursing profession choose to keep the NCLEX-RN, the exam and preparatory materials must be translated according to a methodical and rigorous process. Moreover, the translation must be better coordinated to ensure the exam and the preparatory materials meet a high standard of quality. Therefore, the Committee recommends:

Recommendation 3

That Public Services and Procurement Canada, in partnership with Health Canada, propose to the Canadian Council of Registered Nurse Regulators that it coordinate all translations or adaptations of the NCLEX-RN and preparatory materials with the Government of Canada’s Translation Bureau.

Even though they were not included in the decision to select the NCLEX-RN, francophone and bilingual post-secondary institutions must deal with the lack of preparatory materials in French. Given Health Canada’s commitment to OLMCs, it appears necessary to recommend:

Recommendation 4

That Health Canada provide the Consortium national de santé en français with the funding necessary to coordinate – in partnership with the affected francophone post-secondary institutions in its network and student associations– the development of the tools needed to improve the success rate for francophone registered nurses who take the NCLEX-RN exam in French.

In conclusion, the Committee would like to thank the witnesses who appeared before it for this study and would very much like to see the Government of Canada support the francophone registered nurses and post-secondary institutions affected by this issue. Finally, the Committee hopes that nursing students and graduates across Canada who chose to study in French will persevere.

While the current study does not look at the challenges faced by Quebec’s anglophone minority in training in the field of nursing, the Committee is aware that a similar problem exists.