About the 65% Failure rate on June 2019 Nepal Nurse License exam – some factors to consider

Two-thirds failure rate on June 2019 Nursing License Exam

The recent pass rate for the Nursing License Exam in Nepal was 35% announced in July. In other words, 65% of the examinees failed the exam. The exam is a two-and-a-half-hour paper and pencil test with multiple choice questions in English, and while the scores are not released, the test-take must answer at least 50% of questions correctly. A sample of typical questions on the exam can be found here: https://www.slideshare.net/rsmehta/nepal-nursing-council-licencing-exam-mcqs-sample These sample questions were published around the time of the 2012 exam. 

The announcement about the exam from the Nepal Nursing Council

There was a reaction in the media, and throughout the country. https://myrepublica.nagariknetwork.com/news/nursing-license-results-stir-debate-on-quality-of-training/  Nursing education is expensive in Nepal and many young women enter the field with the idea of possibly working in Australia, the EU, Gulf Countries, or the USA to earn remittance money.  For many years, an upper-caste young woman would have never been allowed to pursue nursing as a career, but this has changed dramatically in the last ten years or so, as it has become recognized that a woman working outside the home in a foreign country can send money back. A parallel trend exists in Medical education here as well. 

PCL education is a challenge

The vast majority of women enroll in Proficiency Level Certificate (PCL) programs, and there are eighty such around the country. You can enroll in PCL even if you don’t pass the SLC exam. The SLC is referred to as “the iron gate” and these days about 20% do not pass. This is better than it used to be. In other words, after passing tenth grade at the age of sixteen a girl can enroll in nursing school here. She could graduate at the age of nineteen

If the nursing exam was constructed by the same people who were in charge of the old SLC exam, that is a problem. The SLC mindset was to disqualify everyone, not to really measure anything. Any good teacher soon learns that it is easy to construct an exam that nobody can pass, not even themselves. 

During the time of the Constituent Assembly, the Nursing Council attempted to institute a system of regulating the establishment of new nursing programs, but they were over-ruled in a dramatic fashion when a different political party came to power. The government took control of new nursing programs and loosened the requirements to start a PCL program. At the time, the Nepal Nursing Council leaders were replaced. There were rumors that money changed hands.

Population Boom a Factor

Now, to be fair, the government had a problem at that time, which was how to provide a career path (other than homemaking or shopkeeping) for young women, since there are so many young persons in Nepal. There has been a “baby boom” and to create the future, jobs must be created. PCL nursing was proposed as one avenue to prepare girls from the village for hospital work. Often, the government advisors did not really have an understanding as to the responsibilities of nurses and the knowledge base required. In about 2013, I recall attending a lunch with an American anthropologist and some women’s advocates who were in favor of relaxing the standards of nursing education mainly to give employment, heedless of any academic requirements. They wanted to create lower levels of health workers that would not be as stringent as nursing education. They failed to see that this was a step backwards, not forwards. 

Previous Problems

The high failure rate of the licensure exam is not a new thing. In 2014, the first year it was implemented, there was an outcry due to the failure rate. At that time, I wrote in my blog that I believed the minimum education prior to admission to nursing school should be “SLC plus two” – meaning that an additional two years of science education should be taken, and thereby increasing the age at which a woman is admitted to nursing school, to eighteen with a resulting higher maturity level. At the time, B SC programs were just coming into existence in Nepal. There has always been a paradox in B Sc nursing education. Nurses trained at the B Sc level are less likely to be subservient to doctors and are trained to speak up on behalf of the patient. At many hospitals, doctors perceived them as a threat and resisted hiring B Sc nurses since they were more likely to advocate for holding the doctors to a higher standard. In those days fewer women attended MBBS programs. B Sc education needs to be covered in a separate blog. 

I have written about nursing and nursing education issues in Nepal since 2011 on this very blog, and you can browse the 270 previous entries to see the general focus of my work. I first came to Nepal in 2007 to teach at Tansen Nursing School ,a PCL program in Palpa district. 

There has not always been a licensing exam for nurses in Nepal. This was started around 2012, partly because the International Council of Nurses pressured the Nepali government to comply with international standards for nursing education so as to promote the portability of a nursing education across national borders. In other words, without adequate credentialling, a nurse who moved to another country from Nepal would be required to take their nursing education all over again from the beginning before becoming eligible for licensure in a new country.  

At the PCL level it is not uncommon for the nursing faculty to only have a PCL degree themselves and be only a few years older than the students. There are fewer role models. This has been changing but not quickly enough. 

Which Language to use for exam?

Now, the language of instruction and the language of the textbooks is an issue. Most textbooks are written in English, and supposedly the language of instruction in nursing is English. The licensure exam is in English. This presents a variety of problems. First, even if the textbooks were in Nepali, Nepali is not the first language of many of the students and it would not be feasible to write editions of each book in, say, Maithili or Bhojpuri. Next, despite the official language of instruction being English, there are commonly accepted ways to work around this, and these exist throughout all levels in the Nepali system of education, form the very beginning. Many schools use the least amount of paper for their students and rely on memorization. 

How people study in a resource-limited environment

In nursing, nobody can afford to buy a personal textbook; libraries are not amply stocked, and the jargon of medicine and nursing is difficult to learn ( this is true even for American nursing students). There is a lot of highly specialized vocabulary. Nobody studies “alone” – they study in groups. In other words, five students get together, the best English-speaker reads it out loud, and they discuss it in Nepali to gain comprehension. In the cities more students own a laptop but this is not the case everywhere.

There is nothing wrong with Nepali language

Use of Nepali bhasa is actually close to what it should be. This is Nepal; the patients speak Nepali; the nurses will work in Nepali language to meet Nepali health needs. But there is tremendous variability of English language proficiency across the country. If you meet a nursing student in Kathmandu who is fluent, do not think that they represent all nursing students everywhere. In my classes that I teach, I start each session with a quick survey of language ability since I lecture in English. 

Need to re-evaluate the exam itself


I looked at the sample question in the link above from 2012, and I would say that these do not reflect what we would call a “nursing focus” in USA. In brief, the questions rely too much on nurse’s vocabulary and not on the actual decisions a nurse would need to make. In USA there are many examples of the type of question that would appear on the licensure exam. Dozens of sites showing sample questions can be found by Google. For that matter, the National Council of State Boards of Nursing in USA publishes their own test map, and it is very very different than the one for Nepal, being “concept based.” My experience constructing exams in USA tells me that none of the questions in the 2012 sample would be acceptable. Also, when a nurse struggles with language, is it reasonable to impose a 180-minute limit on the exam? Are there numbers available as to who was unable to complete the exam in this time?

So, the exam results leave many questions unanswered, starting with the validity of the exam, the way it is delivered, and the way it is used.

Please feel free to share, and to comment below. I invite feedback on this blog, especially if it will improve accuracy. If you wish to give feedback but are reluctant to speak publicly, send an email to me at joeniemczura@gmail.com 

Next Blog?

Also, I will add another blog on the topic of what I think needs to be done. Stay tuned.

About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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1 Response to About the 65% Failure rate on June 2019 Nepal Nurse License exam – some factors to consider

  1. A few days after this was posted, another reaction was published: https://www.swasthyakhabar.com/story/28453?fbclid=IwAR1HGftpJikVg2mzKvJRtftK0AF6owIVUn0LtqiAPAY1VC60Bf0QLYLYeNc

    सञ्चार माध्यममा हालसालै लाइसेन्स परीक्षामा ६५ प्रतिशत नर्स फेल भएको समाचार आयो। यो समाचार पेसामा संलग्न नर्स, सुभचिन्तक एवं सेवाग्राहीका लागि तितोपन दिने किसिमको छ। नर्सिङ पेसालाई सुदृढ बनाउन बल लगाइरहेकाहरुको त रातको निद्रा नै खोसिदियो यो समाचारले।

    काउन्सिलको लाइसेन्स नपाउनु वा अनुत्तीर्ण हुनु भनेको ती नर्सहरु कुनै पनि संघ/संस्थामा नर्स भई सेवा दिन अर्को परीक्षा दिएर पास नभएसम्म अयोग्य ठहरिनु हो।

    समाचारमा मापदण्ड नपुगेका कलेजले नर्सिङलाई मागिखाने भाँडो बनाएको र आफ्नो अस्पताल नभएको वा जहाँ प्रयोगात्मक शिक्षाको निम्ति लगिन्छ, त्यहाँ बिरामीको चाप कम भएको समस्यालाई चित्रण गरिएको छ। समाचारले गुणस्तर कायम गर्न सिटिइभिटी, मन्त्रालय र काउन्सिलबीच समन्वय हुनुपर्ने भनाइ राखेको छ। समाचारमा दिइएको जनाकारीमा सहमति जनाउँदै केही अन्य जिम्मेवार पक्षका बारेमा केही उल्लेख गर्न चाहन्छु।

    प्रथमतः नर्सिङ काउन्सिलले निरीक्षण गर्दा पूर्वजानकारी दिएर जाने कारणले कलेज र सम्बन्धित अस्पतालले आफ्नो कमजोरी देखिने छिद्रहरु टाल्ने मौका पाउँछन्। त्यसैले छड्के जाँच गरी मापदण्ड नपुगेका शैक्षिक संस्थाहरुलाई पारदर्शी ढंगले कारबाही गर्नुपर्छ।

    नर्सिङ पेसालाई अत्यन्त हलुका ढंगले मूल्याङन गरी जो कोही पनि छात्राहरु पनि यो पेसाप्रति आकर्षित भएको देखिन्छ। तर पेसाको जटिलता हेर्दा अभिरुचि राख्दैमा नर्सिङ पढ्न र काम गर्न सकिन्छ भन्ने होइन।

    १८/१९ वर्षको उमेरमा जीवनको जटिल एवं संवदनशील क्षणमा काम गर्ने बुद्धि, विवेक, सिप र योग्यताको विकास गर्नु अत्यन्त चुनौती छ। नर्सिङ पेसालाई औषधि बाँड्ने, सुई लगाउने र ड्रेसिङ गर्ने दायरामा मात्र मूल्यांकन गरी पढ्न आउने र आइसकेपछि कठिनाइपूर्ण अध्ययनका कारण तनावग्रस्त भएका विद्यार्थी प्रशस्तै भेट्न सकिन्छ।

    नर्स पढाउँदा विदेश पठाउन सजिलो हुने लहुरे वा डाक्टर ज्वाइँ पाइने आशामा मात्रै इच्छाविपरीत छोरीलाई नर्सिङ पढ्न कर लगाउने अभिभावक पनि यो नतिजाको जिम्मेवार हुन्। अभिभावकको करमा वा विदेश जाने धुनमा गरिएको अध्ययन कस्तो गुणस्तरको हुन्छ, हामी अनुमान लगाउन सक्छौं।

    अनुत्तीर्ण ६५ प्रतिशतमध्ये सतप्रतिशतले विदेश जाने उद्देश्यले पढेकोले फेल भएको वा विदेश गएर काम गर्नु गलत भएको ठहर गर्न खोजेको होइन। तर जुनसुकै उद्देश्यले पेशामा आए पनि सेवा भाव र दक्षता प्राप्तिको उद्देश्यलाई नर्स पेशामा आवद्धहरुले सपनामा पनि बिर्सन मिल्दैन। होइन भने नर्सिङ सेवामुखी पेशा हो भन्न डराउनुपर्ने अवस्था सिर्जना नहोला भन्न सकिँदैन।

    (श्रेष्ठ महाराजगञ्ज नर्सिङ क्याम्पसमा स्नातकोत्तर तह प्रथम वर्षमा अध्ययनरत छिन्।)

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