Proposed changes to the Registration Regulation and Annual Fees
The Registered Nurses' Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario. RNAO regularly provides CNO with feedback regarding regulatory matters and we are pleased to offer recommendations on proposed regulatory and fee changes as circulated in the June 2016 The Standard.
Proposed Changes to Registration Regulation under the Nursing Act
- Removing “in Ontario” requirement from the declaration of practice.
RNAO commends CNO for reversing the “in Ontario” requirement from the declaration of practice. This was a recommendation made by RNAO in our 2014 submission to CNO (Appendix A). Removing the Ontario-based practice declaration is appropriate because nursing practice is based on the same body of clinical knowledge as other provinces and the United States. As a result of the requirement that was put in place in 2013, thousands of nurses, many of whom work across borders, have either resigned their CNO registration or been forced to enter the non-practising category. In 2015, the number of non-practising RNs almost doubled from 2014. This depleted the nursing workforce potential, at a time when Ontario has the lowest RN-to-population ratio in Canada at 711 RNs per 100,000 people compared to the Canadian average of 841 RNs per 100,000 people.
RECOMMENDATION #1: Proceed with the removal of the “in Ontario” requirement from the declaration of practice.
- Changes to Exam Requirements
RNAO understands the proposed amendments enable the Council to decide whether registration exam attempts should be limited and to what extent. It is also our understanding that CNO intends to impose no limits on the number of times an applicant can write the NCLEX-RN exam.
Even if applicants are granted unlimited exam attempts, there would be an indirect limit imposed based on a currency requirement for nursing practice. According to Ontario Regulation 275/94, applicants must have practised nursing within the last three years – this requirement includes nursing school. The National Council of State Boards of Nursing’s (NCSBN) exam retake policy enables applicants to take the NCLEX-RN exam once every 45 days. In Ontario, this translates into 24 attempts over three years.
RNAO urges CNO to consider the public safety perspective. An entry-to-practice regulatory exam is a safeguard to ensure that applicants have the entry-level knowledge necessary to provide safe care at the beginning of their career. There are many reasons why an applicant may fail the examination, including the potential that they are not ready for practice. In each attempt, the NCLEX-RN poses different questions but consistently evaluates whether an applicant meets a standard of competence. If applicants are unable to meet this standard after a specific number of attempts, there should be a safeguard in place to protect the public. RNAO proposes a model where after a pre-determined number of attempts of the examination within a pre-determined timeframe - determined by the regulatory bodies based on best practices - an applicant would be required to complete a time-limited (e.g. two months) Ontario-based remedial program. Upon successful completion of the program, the applicant would be granted additional attempts to be completed within a pre-determined timeframe.
Statistics demonstrate pass rates decrease with repeat attempts at the NCLEX-RN. In 2015, RNs educated in the United States that wrote for the first time had a pass rate of 84.5 per cent compared to repeat writers that passed at a rate of 44.5 percent. These numbers are even lower for internationally educated RNs writing in the U.S. with 31.4 per cent passing on their first attempt and 18.0 percent passing after repeated attempts.vi Some states have addressed this concern by requiring applicants to complete a remedial education program after a set amount of failures. In Michigan and New Jersey, individuals can attempt to write the exam up to three times after which they are required to complete a remedial educational program before they are issued another three attempts. Similarly, in Florida, after three failed attempts, a remedial course must be completed before individuals will be permitted to write a fourth time.
After graduation, applicants for registration are no longer supported by their universities and rely on for-profit courses to prepare them for the registration exam. The fee to write the exam in Canada is $360.00 and some applicants incur travel expenses to get to the test site. These courses, along with the fee to write the NCLEX-RN exam and travel expenses are quite burdensome, especially for new graduates. Temporary registration with CNO is revoked after the first exam failure adding increased stress and financial hardship for applicants. It is unjust to permit applicants to exhaust their attempts at writing the NCLEX-RN and/or endure excessive financial hardship to re-write the exam multiple times with no intervention.
Therefore, RNAO urges CNO to explore options to create a time-limited (e.g. two months) Ontario-based remedial program for applicants that have been unsuccessful in passing the NCLEX-RN after a pre-determined number of attempts within a pre-determined timeframe (both determined by regulatory best practice). This program will have to be accessible and affordable across the province to ensure equity for all applicants.
RECOMMENDATION #2: Proceed with amendments that enable Council to decide whether registration exam attempts should be limited and to what extent. For public safety, RNAO supports a model where after a pre-determined number of attempts of the examination within a pre-determined timeframe - determined by the regulatory bodies based on best practices - an applicant would be required to complete a time-limited (e.g. two months) Ontario-based remedial program. Upon successful completion of the program, the applicant would be granted additional attempts within a pre-determined timeframe. RNAO encourages Council to review established processes in other jurisdictions and consult with stakeholders to determine: 1) the pre-determined number of attempts and timeframe to take the exam and 2) the parameters warranting completion of the remedial program, its delivery and the content of the program.
- Minor Corrections
RNAO has no concerns regarding the minor corrections proposed by CNO.
Proposed Changes to Annual Fees
RNAO recognizes the work of CNO to meet its regulatory mandate as well as the need for sufficient resources to ensure it is done effectively. With the upcoming initiatives to expand the Quality Assurance Program and launch the new Nurse Health Program, RNAO supports the incremental fee increase approach as approved by Council:
OPTION 3: Implement incremental fee changes as follows:
in 2017, increase the fee by $35 to $190
in 2018, increase the fee by $10 to $200
in 2019, increase the fee by $5 to $205
in 2020, increase the fee by $5 to $210
in 2021, no fee increase.
RNAO is very encouraged to see the development of a Nurse Health Program and looks forward to partnering with the College and other associations. We want to ensure that the program is sustainable and recognize that this will require additional resources. The incremental approach gives members predictability for the fee increases and minimizes the impact of a large one-time increase.
RECOMMENDATION #3: Proceed with Option #3 – Implement incremental fee changes.