Designed in USA, used in Canada

Design does matter. It matters as much as where something is made – just think about the simple phrase that comes with most Apple products: “Designed in California, Assembled in China.”

Recently, 10 nursing regulatory bodies gave away a significant right to the design and quality assurance of Canadian nurses to an American nursing organization. On December 2nd 2011, ten provincial nursing regulators announced that the National Council of State Boards of Nursing (NCSBN) would begin to deliver the entry-to-practice examination for registered nurses (RNs) in Canada, as of 2015. The announcement was quite subtle and carefully crafted to minimize the perceived impact of this change.

The announcement in Canada focused on a few things: the exam will become computerized, be delivered in testing centers across the country year round (a good thing), and test results would be available much quicker than before. However, the regulators failed to mention the Canadian exam will now become the NCLEX (the American nursing entry-to-practice examination), and will no longer be the Canadian Registered Nurses’ Examination (CRNE).  The corresponding announcement in the US was much clearer: NCSBN to bring the NCLEX to Canada.

Please don’t think I’m crying wolf or in anyway think something American is inherently evil, bad or wrong. I do not believe for a minute that Americans are to be feared or are in any way bad people. The issue is the distinctly different values our countries have on issues of healthcare delivery and funding.

The real reason Canadians should be aware of this change is the impact it may have on their nurses’ values and value. RNs take a Bachelor of Science of Nursing (BScN) which upon graduation makes them eligible to write the entry-to-practice exam. Our universities will still control curriculum, but they also have an obligation to students to prepare them for the entry-to-practice examination, whatever it may be. This means that the education which Canadian taxpayers subsidize, and Canadian nurses pay for, will carry the values of an American examination. This could very subtly and significantly impact nursing values. As an example, on a NCLEX question such as the one below, a Canadian nursing student would have a difficult time choosing the right answer, because our values and healthcare system are so different.


According to the NCLEX, the answer most Canadian nurses would give is wrong. While there are not always enough organs for Canadian patients, our system will provide care to any patient that requires a transplant, if it is a viable option (they would be able to survive/recover from the surgery and it would improve their quality of life). So do you want your nurses learning (and getting tested on) American values like distributive justice for patients who do have insurance to pay for a liver transplant, a problem that will never arise in Canada?  Or do you want your nurses to be taught Canadian values like their responsibility to advocate and be accountable for a patients needs?

Additionally, writing the NCLEX could result in more Canadian trained nurses migrating to the US, since this examination will make them eligible to practice there. This may increase the cost to retain nurses and make it more challenging to maintain adequate hospital staffing requirements.  Anyone concerned with health and human resources can attest to the growing demands on our healthcare workforce. Not only does this switch have the potential to leave Canada short of nurses as demand for health professionals and nurses increase, it may also change the way nurses are educated and the values of the profession. For more, listen to the Canadian Nurses Association’s reaction, and feel free to check out their petition.

The comments section is closed.

  • riyasharma says:

    i am canadian permanent resident having bachelor’s of degree in nursing from india. I want to give Nclex RN exam in california..i want to know if i am eligible to give exam in states? I am having tourist visa for usa.

  • Verona Thompson-Allen says:

    I think it’s a good idea to use the unclex. My daughter is Canadian living in the US and she’s on RN. So that’s a big plus for her. I am a Canadian as well living in the US. I am on LPN and it would be nice to home and find a job in my field because I’ve taken the unclex as well is the RNs. I think the LPN should get the same opportunity.

  • joni says:

    The exam will have question pertinent to Canadian practice since the questions will be composed by Canadian nurses.

  • Lindsey says:

    I feel that some of these comments are disrespectful to the US. If Canada wanted to have there own “biased” CAT (computer adaptive test) then why couldn’t 10 provinces come up with a solution when they had the chance? Instead, here you are complaining about this and that and how the healthcare is so different…DUH! The NCLEX-RN exam tests basic skills of a nurse all the way from Cardio, L&D, GI/GU, pharmacology, cultural differences ( if any country should know about cultural diversity, it’s definitely the US) and YES math conversion equations to the metric system…. This is what EVERY nurse no matter where he or she is from should be tested on…IT’s all about SAFETY of your patient’s!!! Anatomy is anatomy…No where on the NCLEX-RN did I ever see or hear one question about “how to bill a person” or “insurance questions” or “how long can a patient stay in a hospital”…This is not a “Social Studies” exam! A practicing nurse will learn about these types of things with orientation to whatever facility he or she is employed. And another aspect that blows my mind is: If a student has been successful on the NCLEX prior to 2015, why should they have to repeat it, just to work in Canada…So what if NCSBN is changing the exam (THEY CHANGE IT EVERY 3 YEARS ANYWAY FYI)…NCSBN has clearly stated that the exam WILL NOT be geared towards CANADA or the UNITED STATES…Again it’s all about pathophysiology knowledge, health promotion and safety!

  • Randy says:

    Hello, my name is randy and i am certified in US as a First Responder, Nursing Assistant, soon to be Administrative Assistant and i plan on going into doing practical nursing in the US. My question is that if i take my NCLEX for LPN here in the US will i have to re-take it in Canada to be able to work. (i plan on working in Ontario by the way)

    • Robert Fraser says:

      Hi Randy,

      Just as an upfront disclaimer this blog does not represent the opinions of any Canadian regulators. The organization you should be contacting, if you plan to practice in Ontario, is the College of Nurses of Ontario http://cno.org . That is the nursing regulator in Ontario for Registered Practical Nurses (what our provinces calls LPNs).

      That being said I could not put bet that your license would be directly transferable. First, you need to look at the educational standards for the RPN, and see if your experience matches. I know Canada has some higher standards (i.e. becoming an RN in Canada requires an 4 year degree), so even if you have a similar title it may not be equivalent in Canada. After education then you will likely need to do some equivalency test, or jurisprudence exam (tests knowledge of law, regulation in local context).

      Sorry I’m not more of an expert on the various nursing positions and international equivalences. I do appreciate you taking time to comment so I wanted to respond.

      Hope this helps a little bit.


  • lindsey says:

    I am a Registered Nurse in California, can I worked as an R.N. in Toronto on 2015 with my license in California. thanks

    • Rob Fraser RN says:

      Hi Lindsey,

      I definitely would not count on that. They will still be working on the implementation of the exam changes for Canadian Nurses. Unless you see serious progress on the issue I would not expect the american NCLEX to be accepted in Canada yet. Especially, since the regulators want the ensure that it is or at least appear to have a unique exam.

      I think the only thing you will be able to expect is if you want to practice in Canada the licensing exam will be very similar to exam you took in the US. The other thing that would be different is the requirements to the be eligible for RN practice, which in Canada requires as Bachelor of Science in Nursing.

      Hope that helps,

  • John says:

    I am an US educated RN working in the states but lived in Toronto for my first degree in Computer Science. I have always wanted to move back to Canada and I hope this will make the immigration process a little easier.

    In regards to possible nursing shortage with NCLEX coming to Canada, I don’t think it will be a problem as long as the salaries are competitive. (supply and demand)

  • Amanda says:

    Hello Rob & others,

    Just this past week I had the opportunity to attend the National Students Nurses Association conference in Pittsburgh. The career fair had many companies selling products to help students study for the NCLEX so I took this opportunity to ask what they knew about the NCLEX coming to Canada. Only 1 of the 4 vendors I talked to knew that the NCLEX was coming to Canada, and the one vendor that did know knew that and nothing more. This worries me, according to the regulatory bodies the NCLEX will be adapted to Canadian culture and standards of practice, but if the companies who are making the resources to help us students study for the test do not know about this, how are they supposed to adapt their materialsÉ (sorry my question mark button is not working!) It takes a long time for companies to adjust their products and I am afraid there will not be resources out for students by 2015 to help them study for this Canadian adapted NCLEX exam.

    The next issue I would like to bring up in regards to the NCLEX is the ability of the provincial regulators to influence the questions that are on the exam. When talking with the NCSBN booth, they stated that Canadian provinces are a part of the association, but are only affiliate members and do not have a vote. They also stated that they could not see that the Canadian provinces would get a vote in the future either, however this was just a speculation. In saying this, even if the provincial regulatory bodies have the ability to vote there will be approximately 10 votes compared to the 30 some votes coming from the United States, this provides a huge opposition to adoption of question that reflect Canadian standards of practice and values.

    Another concern I have is about CNA, obviously CNA makes a lot of its profits from administering this exam, and without this profit what will be the future of this organizationÉ (again, question mark does not work!) I have no idea how badly this lack of revenue will affect CNA, and whether it would come to the point of questioning the future of CNA, but if it did Canadian nurses should be very concerned about this!!!

    • Alberta RNs says:

      Hi Amanda,
      It is not surprising that companies selling products to help NCLEX writers have little detailed information at this point. The contract between the Canadian RN regulators who are purchasers of the new exam and NCSBN is still being negotiated and it is only after the contract is signed that exam content development will begin. We have every confidence that NCSBN’s process of informing vendors about exam content will provide the information they will need to develop new products in time for introduction of the new exam in 2015.

      Whether or not a Canadian RN regulator is an associate member of NCSBN has absolutely nothing to do with development of the new exam. Some of the Canadian regulators purchasing the exam are associate members of NCBSN; others are not. The involvement of Canadian subject matter experts in development of the content for the new exam is part of the negotiated contract with NCSBN and it is that process which will ensure Canadian input is properly weighted. The Canadian subject matter experts will also be able to veto any question which is biased.

      Hope this helps.

    • Rob Fraser says:

      Hi Amanda,

      Thanks for sharing your thoughts and concerns. This change is a significant shift and will have serious impacts, for better or worse. I think this is what concerns most students and nurses.

      I am not sure what the plan for learning materials to support the exam might be. This is a revenue generating service, so I’m sure that nursing schools and experts will be working as quickly as possible to create something as soon as they receive details. Hopefully it will be soon enough for students, and there will be multiple publishers/providers developing quality resources.

      I agree with you that the influence Canadian nurses may have on the exam will dramatically decrease. As Alberta RNs points out, there is still a practical – which I wonder how significant it will truly be – way that the Canadian regulators will be able to oversee the new test. My assumption is that there will be a small group of subject matter experts that will be asked to review the NCSBN test. They may provide input or veto questions, and that is likely to be the extent of Canadian input.

      Currently, in my opinion there is much more formal and informal input from Canadian nurses. Not only would those writing the exams be Canadian, that group would change year or year increasing the diverse perspectives involved. Additionally those nurses have conversations with colleagues and peers about the exam, the positive and negative, which creates more informal feedback. The nurses participating in exam development were often faculty and staff of our nursing schools and hospitals, which means that they are influenced by: exam outcomes, academic discourse, changes in our healthcare system, changes in our patients’ needs, and other factors as well. These informal influences may be lost.

      I’m still not convinced we can predict how the decrease of informal inputs will impact the exam when the NCSBN begins to write it. The potential impact on content and academic curriculum will be very hard to predict. I hope that the regulators continue to engage everyone in the process and students such as yourself continue to ask important questions and raise your concerns. Developing and strengthening out profession means working together to overcome all the changes and challenges we face.

  • jon says:

    I think this is a great news for the fairness of testing. I have taken many professional exams in both Canada and US, and I can tell there is a big difference is the way the exams are administered and graded. In Canada for example, taking a test is still done in pencil that easily can be forged. The time to release the results in Canada can take longer than 3 months, and the question with no answer is: why? A computer based exam is neutral if it is administered by a third party company. Many grading systems used in Canadian testing, use extremely fussy equating formulas that, if you try to read and understand, can make you go crazy and disgusted, because it is impossible to comprehend how they come up with the grade. A widely used testing and grading system used in US will bring the much needed fair environment that will also cut cost and open more opportunities of getting tested. I would hope that other testing boards would adopt the US type of exam.

  • Andrew says:

    I am a Permanent Resident in Canada with a US RN License which I got last 2008 when I was still in the Philippines. Though I am waiting for the results of the CRNE I took last Feb 2012, would this shift of Examination type also mean that US RN holders prior to Jan, 2015 are eligible to practice as RN’s in Canada?

    This shift does open a lot of possibilities.


    • Robert Fraser MN RN says:

      Hi Andrew,

      Great question, and another perfect example of why Canadians should be directing a lot of questions towards the nursing regulators. These are some of the questions that have not been answered, due to the lack of public engagement. At this point I would make not assumption that it will guarantee eligibility of registration in Canada. I’d encourage you to email the regulatory body within your province to see if you get a clear and direct answer. If you do, please feel free to share it.

      All the best,

    • Alberta RNs says:

      Hello Andrew,

      The short answer to your question is no. The new RN exam will not take effect until 2015 and this is a go forward, not a retroactive, decision. The Canadian regulators did not agree to adopt and/or approve the current exam administered in the U.S. as equivalent to the new entry-level exam. The nursing regulators and NCSBN have agreed to develop a new exam that will be administered to applicants seeking licensure.

      It is extremely important to remember that passing the new exam will continue to be only one of several requirements applicants must meet to obtain licensure. Each province/state/territory or jurisdiction sets its own requirements and all of these must be met to obtain a license to practice. In Alberta for example, passing the current entry-level exam is currently listed on CARNA’s website (www.nurses.ab.ca) as one of 10 minimum requirements that applicants educated outside of Canada, like yourself, are expected to meet before they are considered eligible for licensure. In 2015, the current requirement to pass the CRNE will be replaced by a requirement to pass the new RN exam. As Rob suggests, the best idea is to contact the regulator in your jurisdiction for information specific to your own situation with respect to licensure.

      • Robert Fraser MN RN says:

        Thanks for jumping in! This is great to have quick feedback and ideas about how to follow up more. I really appreciate you taking the time to respond!

      • AlbertaRNs says:

        CARNA is hosting a free live webinar tonight, February 28, @ 5 p.m. MT / 7 p.m. ET. We’d be pleased to have you join us. To join the webinar go to http://www.nurses.ab.ca for more details. If you can’t make it, the webinar will be recorded and posted to our website in a few days.

        CARNA has also hosted public information sessions in Calgary, Edmonton and Lethbridge and presented sessions to several groups of nursing students and faculty to provide facts about the new RN entry to practice exam and to address concerns.

  • Ontario RN Student says:

    With American Association taking over the Canadian Registered Nursing Exam, will this affect the the number of chances given to rewrite the exam? Right now, CNA offers three chances to rewrite it, but in US the chances are unlimited.

    • Rob Fraser MN RN says:

      Hi Ontario RN Student, That is a great question, and one I have no capacity or authority to answer. If I have the opportunity to discuss this though with any of the nursing regulators I'll get back to you. If you truly have a burning desire to know you might want to send an email to your provincial regulator. From my perspective, you should not expect this exam change to guarantee any changes to the current limit of three. Instead it may simply offer the regulators the ability to amend that rule with the new style (adaptive-computer exam). This is a style of exam that changes as you get questions right or wrong, to extend or shorten the test. For example, from my understanding if you get 10 questions on a particular topic (cardiology) correct, it would not continue to ask questions linked to that competency. If on the other hand you got 4/7 right if may continue to ask questions on the topic to see if you are able to meet the requirements. This is over simplified as the question difficulty and information included in each question is also incorporated. That being said it may change the provide regulators with the an ability to offer a resolution to the issue of students being barred from ever retaking it after 3 attempts. Again, a great question and one that should be asked of the regulators. Hopefully as we begin to hear more about the issue this will be answered, but it might not be closer until 2015 until we know the full intended changes the introduction of this exam may bring.

  • Rob Fraser says:

    Regarding shift of nurses I think you are right that it will allow for greater mobility of healthcare workers. Where Canada would have a net gain or loss, or any change, is impossible to predict. The implications of making it easier to recruit foreign trained nurses to Canada is an equally interesting one that will need to happen at some point. Regarding the question of Canadian content, it has been made clear that review of the previous exam (CRNE) and Canadian regulations as well as current practice will be done. However, this new exam has yet to be created, and I wonder what contractual options for extending the use of the CRNE are possible if the regulators were completely satisfied by the new exam. From the other comment by AlbertaRNs I think this blog post by the CARNA President helps to shed more light on the position and process that went into the agreement to work with NCSBN: http://www.carnapresident.ca/index.php/blog/new-rn-exam/ I have not seen much released in Ontario, but I'll let you know if I find more. I definitely do not think that any decision made by the regulators would go against their obligations. Although it was a public RFP, the option that they have chosen is without a doubt one that has introduced a number of complexities and unseen implications. Hopefully increasing public raising of concerns will help to ensure that the rest of this process involves more engagement of nurses, organizations and the public.

  • AlbertaRNs says:

    Hi Rob,
    Just want to clear up a few misconceptions expressed in your blog about the new RN exam.
    Canadian Content
    The proposal by NCSBN accepted by the 10 Canadian regulators stipulates that the development of the exam will include the following:
    – a review of Canadian entry to practice competencies and other regulatory documents
    – a practice analysis of Canadian RN practice
    – a review of existing exam bank questions by Canadian RN subject matter experts for cultural sensitivity with veto over any inappropriate items
    – involvement of Canadian registered nurses in new exam question development.

    The results of the RN entry-to-practice exam are used by regulators to help ensure that only individuals who demonstrate competence are eligible to practice nursing in Canada, a responsibility the regulators take very seriously.  They  have taken substantial measures to ensure the proposed exam will reflect nursing and nursing education in Canada. Yes, the exam will duplicate the format of the computer-adaptive NCLEX exam used in the United States. However, NCSBN will not simply be providing regulators with the same bank of exam questions currently used in America. The exam questions administered to candidates in Canada will be at minimum, as relevant to Canadian nursing as the exam questions currently used in the CRNE. The regulators recognize how the announcements by the Canadian regulators and NCSBN can easily be misunderstood as being at odds.  Ironically, NCSBN also had to respond to concerns  that American students would be required to write a Canadian exam!!

    The nursing shortage
    Your suggestion that the exam could increase the number of nurses migrating to the US is not supported by evidence. The entry-to-practice exam has not been shown to influence the decision by graduates of where they will practice. In fact, it points to the opposite. The majority of graduates prefer to practice close to where they were educated in Canada. The most significant determining factor is employment opportunities. For example, when nursing positions across the country were slashed in the early to mid-90s, new graduates accepted positions by employers in the United States. In Alberta, the number of nurses requesting a verification of registration to be sent to an employer outside of Canada has remained constant over the past five years even though jobs were cut back in 2010-2011. The reason:  the employment situation was worse elsewhere. Canadian regulators are as sensitive, if not more, as anyone to the effects of the nursing shortage in Canada. I would argue that at any point in time, Canada is as likely to attract American graduates rather than vice-versa.

    Thank you for providing this forum to provide information that will help others make an informed opinion about this recent decision announced in Canada. For more information, please refer to the latest blog post by CARNA President Dianne Dyer and to the Exam Q&A developed by the College and Association of Registered Nurses of Alberta. Many of other Canadian regulators have also posted similar FAQs.

    • Rob Fraser MN RN says:

      Hi AlbertaRNs, Thanks responding, and I appreciate the reference to Dianne Dyer's blog, great to see more public engagement by regulators about this announcement. Clearly there are still issues to address. We will never be able to completely predict what impact this decision will or will not have. Hopefully you agree that discussing any issue is important to minimize what impact, if any, there might be. Overall the intent of this blog post was to raise some of my concerns, which are shared with others, including some nursing organizations. Hopefully all sides can continue to look at evidence, experience, and our values in relation to this decision. A decision such as this deserves to be publicly discussed, and issues need to be explored. To your response about the nursing shortage, I agree that employment opportunities do have significant impact on nurse migration. This does not change the fact that this exam may cause shifts from previously seen nurse migration patterns. Health care providers' decision to move will always involve many factors. I clearly would agree that nation wide cuts backs of employment opportunities, if matched by openings in another country, would lead to a significant shift of workers. However, within provinces you do not need massive cut backs across the board to see some migration changes, because some of the secondary factors (workload, pay rates, benefits, family situation, etc.) are enough to motivate nurses to move to a different province. To my knowledge, this would be the first time that our Canadian exam may serve as an equivalent examination for entry-to-practice to the USA. As mentioned above nurses have a variety of motivations to move between provinces for jobs. Nurses do this because our citizenship allows us to, and our nursing registration easily transfers between provinces (except Quebec). If our entry-to-practice exam makes us equally qualified to practice in the US, than besides the logistics of moving the only additional step is applying for a visa or green card. Has there been studies investigating migration rates among the 10 other countries that have adopted the NCLEX-RN exam? As you said, outflow of nurses is not the only option. Canada may be on the receiving end of the nursing supply with this change. This raises further issues around the ethics of recruitment of healthcare providers from other countries and the potential impact to patient care, job availability, and the values of Medicare. These issues need to be discussed. Hopefully, the regulatory bodies will continue to expand their efforts engage in dialogue with the various stakeholders and public about how they are moving forward to protect Canadian interests and share more about the reasoning behind this decision. Now that the RFP is complete and the decision has been made having a more fulsome discussion will help alleviate concerns held by those who were shocked by this decision.

      • Bill Glaspey says:

        Rob, Curious to know if you have heard if carrent practicing RN’s are eligible for licensing in the US now with this change from the CRNE to NCLEX. Current Practicing RN’s are not eligible to write the NCLEX at least in BC that is. Do you know if that is possible, if there is work in progress etc. please advise.

  • Rachael Kay says:

    Yes, this makes it potentially easier for Canadian-trained nurses to become licensed in the States, but it would also make it easier for foreign-trained nurses to be licensed in Canada, as the NCLEX-RN is currently offered in 10 other countries as well.

    Rob, do you know if there is any information about whether this test will contain Canadian content? I have not been able to find any mention one way or the other, and I would be surprised if the regulators would accept a proposal that would not include the regulations that they work to uphold. It would be great if you could point me to any mention in the media about content specifically.


    • terra says:

      Your absolutely right Rachael, As a Canadian born, US educated RN. I plan on coming home with my expertise I have picked up along the way. I work downtown Chicago, in one of the countries largest trauma centers. I feel my exposure to different crisis will make the Canadian Health care just a little bit better in my small way. I miss home, I miss good Canadian people.


Rob Fraser


Republish this article

Republish this article on your website under the creative commons licence.

Learn more