The Canadian association and its subsidiary Assessment Strategies Inc. developed and maintain the current pencil-and-paper exam, and submitted a proposal in a recent competition to deliver an online version starting in 2015.
But in early December, regulatory bodies in the provinces and territories — except for Quebec and Yukon — selected the American-based National Council of State Boards of Nursing as a partner to develop a new computer-based test that would be taken by both Canadian and U.S. nurses.
The U.S. market and health-care system are different from Canada's, and that reality needs to be recognized in the exam, said Canadian Nurses Association president Judith Shamian.
"Since I've been involved in nursing leadership in this country ... I have not seen an outpouring of concern on an issue as I have seen on this topic," she said in an interview, noting that more than 12,000 nurses have looked online at materials about the proposed change and that she gets lots of emails daily.
"By and large, nurses are outraged."
Last year about 12,000 candidates across Canada wrote the Canadian Registered Nurse Examination.
The association has drawn up a list of principles that it wants to be followed to ensure the new exam aligns with the curriculum of Canadian nursing schools and reflects the unique qualities and values of the Canadian publicly funded, not-for-profit health system.
It also expressed concern that Canadian exam data and personal information be kept private and not be subject to the USA Patriot Act, which among other things, reduced restrictions on searches of business records in a bid to fight terrorism.
One of the provincial regulators says a criteria of the competition was compliance with Canada's Personal Information Protection and Electronic Documents Act.
The U.S. proposal is "currently compliant," said Anne Coghlan, executive director and CEO of the College of Nurses of Ontario, one of the regulators that chose to go with the U.S.-based exam.
The new exam will include active participation by Canadian registered nurses in writing and reviewing items, and translating the content into French, Coghlan said in an interview Friday shortly after the nurses association held a news conference in Toronto.
"We're entering into a partnership to develop an exam that will be offered in 2015," she said.
"So while the National Council of State Boards of Nursing currently offers an exam, that exam will look different in 2015 because it will be one that is jointly developed by nurses in Canada and nurses in the United States."
The entry-to-practice exam will assess the knowledge required of nurses to provide care in Canada, Coghlan added.
But Shamian is concerned that Canadian nursing students will have to learn about American requirements, and that this new exam could lead to more recruitment of Canadian nurses by American hospitals.
"The current prediction is that the U.S. will be short 260,000 nurses by 2025. Our total number of nurses is 250,000," Shamian said.
"So imagine that they come to us to recruit — and they love to recruit Canadian nurses; they did that in the '90s — and ... it will be so much easier now because our nurses have written the American exam."
Studies done during that exodus of nurses showed that most of the Canadian nurses who left were young and moved south shortly after they graduated, Shamian said. "They marry there, they make a life there, they don't come back."
"We invest Canadian tax dollars to educate our nurses to pay for an American company for a test, and to subsidize their health care system. It doesn't make sense to me."
Coghlan responded that nursing is a mobile workforce, and an exam is only one requirement for registration.
As for new recruits, the cost to write the exam in Ontario is currently $508.50, including taxes. Coghlan indicated the price could drop as administrative costs change.
Coghlan said the competition or Request for Proposal process is legally binding but Shamian is hoping that provincial and territorial governments will step in.
"I am truly terrified that this is going to happen, and in 10 years people will wake up and say, 'Excuse me, who allowed this to happen?' It's unfortunate."
Note to readers: This is a corrected story. An earlier version described Anne Coghlan as president of the College of Nurses of Ontario.