Nursing Exam Failure Rates Spark Review of Test Results

Nursing oversight groups in the United States and Canada are holding the line on testing standards as more would-be nurses fail entry exams. As a result, pressure is growing to make tests easier to pass given widespread nursing shortages, and some critics wonder whether the exams accurately assess students’ true abilities.

When it comes to training more nurses to keep up with growing demand, the US organization that oversees the main licensing exams for nurses decided earlier this month not to change the passing standards for entry-level tests. Meanwhile, nursing text examiners have seen a drop in passing rates for nurses taking the standard licensing exam since the pandemic began.

A similar scenario also is unfolding in Quebec, where the agency overseeing nurse licensing exams announced last month it is holding the line on its passing rates despite an outcry from nurses after more than half of those taking the exam in September failed. Quebec’s commissioner for professional admissions is investigating dozens of complaints from nurses about the failure rate. Nurses who failed the test can sign up to retake it in March.

Joseph Oujeil

Joseph Oujeil, DESS, DEF, has been teaching in Canada for 4 years, now at two Quebec nursing schools. “This is surprising and very shocking to our students as well as nurses from outside Quebec who were [completing] an integration program to adjust their practice to Quebec guidelines,” Oujeil told Medscape Medical News. Students from outside the province failed the licensing exam at a higher rate than their Quebec-native peers, he explained.

Quebec’s professional Order of Nurses of Quebec (OIIQ) responded to the nurses outcry in a press release last month, saying that the pandemic may be partly to blame for the lower passing rate because it made it more difficult to access internships, labs, and face-to-face teaching. Some students weren’t able to demonstrate their ability to practice during the exam as in previous years, OIIQ reported.

Oujeil agreed. “I’m sure the pandemic has an impact on the situation as well as some students did less training in hospitals” because of restrictions caused by the pandemic, he said.  But students also told Oujeil some questions seemed ambiguous.

OIIQ stated in its release that it doesn’t want to lower the standard. The goal is to protect the public “by and with nurses,” to “ensure the competence and integrity of nurses in Quebec” and “promote quality nursing practice,” the release noted.

Similarly in the US, the National Council of State Boards of Nursing (NCSBN) announced December 8 that it would uphold the current passing standards for its entry-level NCLEX tests for registered nurses (RNs) and practical nurses (PNs). NCSBN analyzes the passing standard every 3 years “to keep the test plan and passing standard current,” a press release explains.

Dawn Kappel

NCLEX pass rates have dropped from about 73% for all candidates and 88% for first-time US educated candidates to 69% and 82% respectively in 2021, the last full year for which results are available, NCSBN spokesperson Dawn Kappel told Medscape.

Over the past 3 years, including during the pandemic, the board decided “that the current passing standard is appropriate as a measure of safe and effective entry-level nurse practice,” after reviewing national nurse surveys and the findings of panels of nurses representing NCSBN’s geographic areas in the US and Canada, board president Jay Douglas, MSM, RN, CSAC, said in a press release.

Still, NCSBN is not blind to the larger issues facing nursing, Kappel told Medscape. “There is a huge nursing shortage in the US and Canada. We want as many nurses in the workforce as possible, but we want to ensure safe practice,” she said.

Nursing Student Woes

“Everyone has access to the same test, regardless of which state, province, or country they take it in,” she said. Some international students may not perform as well as US-educated students because of their command of English and the nursing education standards in their home countries, Kappel added.

“Obviously COVID and the challenge of education in general” impacted the results, she said.

Oujeil, the nursing school professor, said he is frustrated by the test results because the majority of students who failed maintained good grades and passed all of their trainings. Yet they scored just below the passing rate of 55%. He said students are proposing the passing rate be lowered to 50%. The current test doesn’t reflect what students are learning in the classroom or during clinical trainings, Oujeil added. “I don’t know of any students who scored more than 60%.”

He said he understands that the mission of the OIIQ is protecting the population, but he doesn’t believe lowering the passing rate to 50% will put the population at risk — and it will help offset the staffing shortage.

“I’m especially frustrated by those who were doing integration programs — mothers and fathers with children with family lives and financial responsibilities. Many of them are good, hard workers and were shocked they should have to pass the exam another time.”

Since 2018, the pass rate on the first attempt at the Quebec test has generally been between 71% and 96%, compared with 51.4% during the exam in September, according to the OIIQ press release. Meanwhile, graduates from 30 of the 55 schools and universities in Quebec teaching nurses performed above the average on the recent professional exam, OIIQ reported.

The professional licensing organization pointed out that nursing candidates have three attempts to pass their exam. “In order to better prepare for their next attempt, all those who failed received an individual response detailing the difficulties encountered. The OIIQ offers all the tools necessary to pass the exam; a detailed guide and preparatory workshops are available online.

“In the run up to the next exams, we will continue to support students by working with educational institutions to provide the optimal conditions for passing the exam. This exam is usually successful and we are convinced that the return to face-to-face teaching, as well as support for students, will be factors of success,” OIIQ President Luc Mathieu said in a press release.

Nursing candidates “who have not passed the exam will be put to work in the network, with the possibility of practicing under the supervision of a nurse…In addition, we will contact health establishments in order to support them in their supervision activities” of the candidates, he said.

Roni Robbins is an editor/writer for Medscape Business of Medicine. She’s been published in WebMD, HuffPost, Forbes, NY Daily News, BioPharma Dive, MNN, Adweek, Healthline, and others. She is the author of Hands of Gold: One Man’s Quest to Find the Silver Lining in Misfortune. Contact Robbins at [email protected].

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