The last hurdle a new nursing school graduate must clear before he or she can practice as a nurse is often the most stressful one: taking the NCLEX-RN®. This licensing examination, developed by the National Council of State Boards of Nursing, Inc. (NCSBN), makes it official: Pass “the boards” (as the exam is familiarly called) and you become an RN.

This grueling, five-hour test of entry-level nursing knowledge and skills can be an intimidating experience for any new graduate. But some minority nursing leaders have voiced concerns that the NCLEX-RN playing field may not be level when it comes to students of color, especially if they were educated outside the U.S. Others dismiss these claims, arguing that the exam is indeed culturally sensitive and unbiased. Either way, strong feelings seem to arise when the subject of the NCLEX comes up.

Charlotte Richmond, RN, PhD, scientific director of anesthesia research at Mount Sinai Medical Center & Miami Heart Institute and an adjunct professor at the College of Health and Urban Affairs at Florida International University, believes that language barriers can sometimes hinder minority and international students taking the NCLEX.

“Here in Miami, the cultural diversity is very great,” says Richmond, who is part Cherokee Indian. “South Florida, particularly, has influences that come from the Caribbean Islands, Central and South America. The majority of international students who are attending the local nursing schools are having a difficult time passing the NCLEX, and it perhaps could be due to language problems.”

Americans use different terminology that international students might not know, Richmond explains. She likens it to the variations in word usage between America and England. “In that sense, the NCLEX questions are based on the American culture and not necessarily [other languages or cultures],” she adds.

Graciela Reyes, RN, BSN, CRRN, a member of the Dallas Chapter of the National Association of Hispanic Nurses (NAHN), agrees. “The [international] nurses’ difficulty is not with the content [of the test] but with the language,” says Reyes, a native of Mexico. “The medical terminology is not that much of a problem, because most of it is very similar in English and Spanish. What gave me the hardest time was the day-to-day English.”

Back in 2001, Jodi Gooden, RN, BC, PhD, an assistant professor in the College of Nursing at the University of Oklahoma, wrote an article for Minority Nurse about culturally biased classroom testing. She believes this same problem persists today. “I see it here where I teach,” says Gooden, who is part American Indian. “What I see today for some minority students is that there is a difference in their language.”

Gooden believes this issue could affect minority nursing students’ performance not just on classroom tests but also on the NCLEX–a situation that she finds particularly unfortunate. “I hate to see students put in a position where they are very knowledgeable in a clinical area, yet because of the NCLEX [and potential cultural barriers] they are limited in whether or not they can become a nurse.”

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A Question of Culture

Language isn’t the only issue cited by those who feel minority and/or international nursing graduates may be at a disadvantage when taking the NCLEX-RN. “Some people don’t believe that cultural differences can be a problem,” says Richmond. “I have taught in three different states and the cultural diversity is different in each one. Language is part of [the potential difficulty for minority students], but the culture is another part of it.”

Jacqueline Crespo Perry, RN, BSN, president of NAHN’s Houston Chapter, agrees that culture can influence what minority nursing students learn. Perry has three nieces who are planning to go to nursing school. “One of them is really deep into her Hispanic roots and it is going to be a little hard for her to adjust to a lot of things she will encounter in her nursing courses,” she says. “The other two will swing right through.”

For example, Perry explains, traditional Hispanic families’ view of health care emphasizes treatment of illness rather than disease prevention. This cultural orientation can affect the way some Hispanic candidates may interpret and respond to questions on the NCLEX.

“When they read a question about children’s health, they are focusing on the illness. They look for the sick child and how you will treat that child,” Perry says. “But because the majority culture emphasizes preventing the child from getting sick, this would not be considered the ‘right’ answer.”

To cite another example, she continues, mental illness is considered a stigma in Hispanic culture. As a result, it is often not talked about, treated, or even taught in some international nursing programs. That knowledge deficiency, which can impair nurses’ performance on the psychiatric section of the NCLEX, needs to be addressed as well, Perry maintains.

In addition, the exam’s multiple-choice format can pose problems for international students, according to Cora Munoz, RN, PhD, an associate professor at Capital University in Columbus, Ohio. A native of the Philippines, Munoz is also a reviewer for the NCLEX-RN at the Kaplan Review Center in Columbus.

“I will not go so far as to say the test is not culturally sensitive,” she comments. “But I think that foreign graduates do have a problem, not so much with content but with format. Multiple choice is not a common testing format in other countries. The format itself becomes problematic.”

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In Mexico, nurses take their licensing exams orally in front of a panel of judges, Reyes points out. “Then you come here, and it’s multiple choice and done on computers.”

Narrowing the International Gap

On the other side of the argument, Barbara Nichols, RN, MS, DHL, FAAN, chief executive officer of the Commission on Graduates of Foreign Nursing Schools (CGFNS), believes the NCLEX-RN is culturally sensitive. The CGFNS has a certificate program that internationally educated nurses must complete before they can sit for their boards in some U.S. states. Currently, 36 states have this requirement.

Nichols, who is African American, says the National Council of State Boards of Nursing has put many safeguards in place to ensure the testing process is fair to everyone. “The NCLEX is testing minimal knowledge,” she asserts. “It is not a test of excellence. It is a test of basics.”

The CGFNS, a private, independent, non-profit organization, was created in 1977 at the height of a severe nursing shortage that had prompted many hospitals to import nurses from the Philippines and other countries to fill their staffing gaps. “At that time, only about 15% to 20% of these nurses educated outside the United States were passing the NCLEX-RN,” Nichols explains. “This was really a big dilemma. You had all of these foreign nurses coming in but not passing the licensing exam.”

Today, statistics from the NCSBN clearly show that CGFNS’ efforts have made a difference. In 2001, out of 8,613 foreign-educated candidates taking the NCLEX-RN for the first time, nearly half (49.4%) passed the exam. But a considerable gap still needs to be closed: The first-time pass rate for U.S.-educated candidates is 85.5%.

International nursing graduates earn their CGFNS Certificate through a three-step process: a credentials review of their foreign education, registration and licensure; the CGFNS Qualifying Exam, a one-day test of nursing knowledge; and the Test of English as a Foreign Language (TOEFL), an English proficiency exam.

Passing the Qualifying Exam, says Nichols, is a good predictor of who will pass the U.S. licensing exam. Fifty percent of the nurses who take the Qualifying Exam pass it, she reports; of that 50%, 90% pass the NCLEX. Those who fail the CGFNS exam receive a letter explaining their score and indicating the areas that need to be improved.

Despite this success rate, not all advocates for international nurses are enthusiastic about the CGFNS Certificate process being linked with the NCLEX. Perry believes it is another obstacle for international nurses. Test fees and translation costs are significant, she points out. If foreign credentials to be reviewed by CGFNS are not written in English, nurses must have them translated and pay for it themselves.

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Reyes, too, feels the CGFNS Qualifying Exam is an extra step that international students shouldn’t have to face before taking the boards. “If CGFNS is saying foreign nurses and U.S. nurses are equally educated, why are they holding international nurses to a higher standard?” she argues.

The NCSBN Responds

What does the National Council of State Boards of Nursing have to say about all this?
“The [NCLEX-RN] includes effective checks to minimize the potential for bias due to culture, gender and other background factors,” NCSBN maintains. “It is important that each [question] development panel is composed of nurses representing each region, a variety of practice areas, and minority populations. . .

“Differential item functioning (DIF) is the statistical approach [we use] to determine potential bias. [Questions] flagged for high levels of DIF are reviewed by a group of trained sensitivity reviewers, consisting of at least five members: one male, one representative of three of the ethnic focal groups of NCLEX examination candidates, one member with prior experience on a DIF Review Panel [and] one member with a linguistic background. . .The panel’s recommendations are forwarded to the Examination Committee for final disposition of the items. Additionally, judgments of trained individuals are used to screen [questions] for potential bias.”

In addition to the numerous content reviews conducted by the NCSBN and its member boards of nursing, the National Council also does two formal reviews looking exclusively at issues of cultural sensitivity, adds Casey Marks, PhD, director of NCBSN Testing Services.

When asked if he believes minority nurses may have more trouble passing the NCLEX than their majority counterparts, Casey answers: “We have no reason to suspect that individuals of the same ability level have anything but equal opportunity to pass the examination at the same rate, regardless of their cultural, ethnic, linguistic or racial background.”

Strategies for Success

The current debate about whether or not the NCLEX-RN is a culturally sensitive, equal opportunity exam is unlikely to be resolved any time soon. But regardless of where they stand on the issue, many minority nursing leaders believe there are steps that nursing students of color and internationally educated nurses can take to maximize their chances of successfully passing the boards.

Munoz advises international candidates to take NCLEX review courses, such as those offered by Kaplan, to gain experience in how to take multiple choice tests and to practice taking exams on a computer. Kaplan’s test-prep centers provide all candidates with test-taking strategies, she says, “but if you have international graduate nurses, probably my recommendation is to spend even more time in this area and maybe on how to handle anxiety when taking a test.”

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Lilianne Cooper, RN, BSN, a member of the National Association of Hispanic Nurses, passed the NCLEX in August 2002. She agrees that preparation is crucial. “I started studying for the exam months in advance,” Cooper recalls. “The way they format the questions, you could be looking at four correct answers and your job is to pick the best one for that particular scenario. It’s the most frustrating kind of question I’ve ever had to work with.”

A recent graduate of Boston College’s William F. Connell School of Nursing who now works on med/surg floors at Brigham and Women’s Hospital in Boston, Cooper says nursing school helped prepare her for the NCLEX experience. “I received the tutoring and support I needed to help me tackle those questions,” she explains. “I basically had to learn how to answer these types of questions from scratch.”

Cooper also bought a NCLEX-RN review book with a computer CD included. “I encourage all nursing students to invest in some kind of computer review to get the feel for the computer format,” she says. “The one I purchased gave me the opportunity to take 100-question practice tests that were timed.”

Many international candidates must take English language courses before they can sit for the TOEFL. To address this need, Perry and Reyes, through the NAHN chapters in their respective cities, each run programs designed to help immigrant nurses from Spanish-speaking countries strengthen their English and other skills they need to obtain U.S. licenses.

Currently, some 42 nurses are taking English classes at the University of Houston through Perry’s program, which is called Nurses Helping Nurses. In Dallas, Reyes has set up a volunteer program in the Veterans Affairs North Texas Health Care System, where she works as a nurse educator. Internationally educated nurses who have not yet taken the NCLEX volunteer in the system’s hospitals, gaining the opportunity to work on their English with other nurses, doctors and patients. Reyes meets with the volunteers at lunch most days to discuss any language problems they may be facing.

The Dallas Chapter of NAHN also provides nursing review courses and helps candidates prepare for the NCLEX. The Houston program assists nurses who fail to pass the CGFNS Qualifying Exam by sending them to a local college to take a refresher class in the areas of nursing in which they scored poorly.

Licensing Has a Price

Many of the experts interviewed for this article believe there is still another area in which the NCLEX-RN playing field is not level: the costs associated with taking the exam. “For those in the minority community who may not be in the same socioeconomic bracket as majority candidates, there could be some disadvantages,” says Cooper. “First of all, [the cost of] taking the NCLEX alone is $300. Then on top of that, if you want to prepare for the test, you have to buy a review book and/or go to a review course. Either way, it’s more money out of pocket.”

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Casquese Chaffin, RN, MSN, MA, a member of the Los Angeles chapter of the National Black Nurses Association, agrees that the cost of review courses could be a barrier blocking some minority students’ access to the licensing exam. She believes the foundations of large companies should be targeted to help foot the bill for such courses.

“These companies target their endowments [to causes] where they can ,” she contends. “It isn’t popular [to spend money] on review seminars for nurses. They won’t get a handshake for that. Until the minority community itself makes some noise–yells, screams and hollers–that won’t change.”

Money can be a big issue for international candidate as well. Munoz calls it the single biggest obstacle for nurses emigrating from the Philippines to the United States. Many Filipino nurses go to Faipan, a U.S. territory near Guam in the Pacific, to take the NCLEX exam before they come to America, and that travel represents an additional cost.

Perry’s Nurses Helping Nurses program is working to help immigrant nurses offset the costs of getting their credentials translated for CGFNS review, which can run as high as $70 per page. “We have found people who have been able to translate for us at a low cost,” she reports. “But you have to be careful. If CGFNS doesn’t think the translator is an acceptable source, they will send it back.”

Cooper thinks some minority students may not be aware of cost-cutting options available to help make the NCLEX process more affordable. “Every little bit helps,” she says. “I believe there are some [nursing employers] that offer reimbursements after new nurses take their boards and get their license. Whether it’s buying a used review book, spending an extra hour after seminar with your professor or even inquiring about a reimbursement at the hospital you applied to, it’s all more than worth it in the end when you get that license in the mail.”

Susan Wessling
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