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