Change a Licensure Exam, Watch the Impact

From the latest US nursing workforce report from the Health Research Services Administration in the US, this striking graph should get more attention.  The plunging pass rates of internationally educated nurses (IEN) on the NCLEX-RN exam have big implications for global health workforce policy.

The first thing you need to know is that the National Council of State Boards of Nursing (NCSBN) changed the format and content of the NCLEX-RN exam in 2008.  The test designers added new testing methods that better validate the actual knowledge, skills, and abilities of internationally educated candidates.  This also occurred during growing global outcry of high income countries contributing to "brain drain" in low and middle-income countries.  The impact of the change on internationally educated nurses is clear and has reduced the number of viable candidates who would be eligible for practice in the US.

At the same time, NCSBN data also show that the overall numbers of IENs applying to take the NCLEX-RN exam have also dropped significantly, reaching their lowest levels in a decade.  The global recession is the most likely explanation for the drop in applications.

What does this mean for the future?  There's an interesting intersection of events coming for the US nursing workforce in the next decade.

• Production levels of the US domestic nursing workforce have reached replacement rates, thus decreasing demand for IENs.  
• The Affordable Care Act's implementation in 2014 coupled with increased retirement rates from baby boomer nurses, who deferred their plans due to the 2008 global recession, will converge in the same year.  In time, this may increase demand for IENs again.  
• Current nursing school enrollment rates virtually ensure that demand for IENs will remain low for at least the next five years.  
• The passing of the Voluntary Code for International Recruitment of Health Care Professionals by the World Health Organization in 2011 also means that watchdog organizations are scrutinizing international recruitment practices more closely. 

How these combined dynamics will impact international nurse migration and health systems in other countries will be an interesting point of study for the next decade.