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Ada Woo, PhD Senior Psychometrician, NCSBN

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1 Ada Woo, PhD Senior Psychometrician, NCSBN
NNAAP™ (National Nurse Aide Assessment Program): Job Analysis, Standard Setting and Next Steps Ada Woo, PhD Senior Psychometrician, NCSBN

2 Outline Overview of test development process
2009 nurse aides job analysis 2010 NNAAP standard setting

3 NNAAP Test Development Process
Job Analysis Content Outline Item Writing and Item Review Subject Matter Expert (SME) Panel Review Editorial Review Building Test Forms Setting the Passing Standard Pretesting of Items Administering Examinations

4 Job Analysis Process “Evidence of validity based on test content requires a thorough and explicit definition of the content domain of interest… characterization of the domain should be based on job analysis.” (AERA, APA, NCME, Standards for Educational and Psychological Testing, 1999, p.160)

5 Background on Job Analysis
Assist NCSBN in describing range of authorized duties and evaluating test plans. Provide validity evidence to support the examination. Conducted at least every five years. Large scale studies using multiple methods.

6 Methodology Document review Review of entry-level CNA daily logs
Review of documents specific to CNA work settings Large scale surveys to NAEs and entry-level CNAs Non-responder study Methodology review by external psychometricians

7 Survey Instruments NA survey NAE survey Work environment
115 NA activity statements Last day of work Education and training Demographic Comments NAE survey Work environment 115 NA activity statements Comments

8 Sample Selection Randomly selected 6,500 nursing directors from hospitals, nursing homes and long term care facilities Each director received three surveys to be distributed to one NAE and two entry-level CNAs Return rates: 485 facilities opted out of the study 21 return surveys due to bad addresses CNA adjusted return rate – 10.7% (n=1,016) NAE adjusted return rate – 11.1% (n=666)

9 Job Analysis Survey Results

10 NA Ethnicity and Gender
Gender: 91.5% female; 8.5% male

11 NA Years of Experience

12 NAE Years of Experience Supervising NAs

13 Client Health Conditions

14 Client Age

15 Shift Worked

16 Most Performed Activities
Activity 1 Year or less NA Activity # N % Not Perform Activity % Perform Activity 107 Ask for help when needed 551 0.00% 100.00% 98 Respect client's need for privacy/confidentiality 550 0.20% 99.80% 19 Follow Standard/Universal precautions (e.g., handwashing, personal protective equipment [PPE], isolation guidelines) 557 56 Allow client to do things at his/her own pace 553 0.40% 99.60% 93 Follow client's plan of care 552 0.50% 99.50% Activity Nurse Aide Evaluator Activity # N % Not Perform Activity % Perform Activity 98 Respect client's need for privacy/confidentiality 643 0.00% 100.00% 19 Follow Standard/Universal precautions (e.g., handwashing, personal protective equipment [PPE], isolation guidelines) 660 102 Follow code of ethics for nurse aides 642 107 Ask for help when needed 0.20% 99.80% 29 Use proper body mechanics 656

17 Least Performed Activities
Activity 1 Year or less NA Activity # N % Not Perform Activity % Perform Activity 26 Perform cardiopulmonary resuscitation (CPR) 551 48.30% 51.70% 7 Assist client to fill out meal menu 554 46.90% 53.10% 23 Clear foreign-body airway obstruction (FBAO) 545 42.60% 57.40% 39 Prepare client for diagnostic test, procedure, or surgery (e.g., NPO) 41.50% 58.50% 46 Collect and label stool, urine or sputum specimens 552 37.30% 62.70% Activity Nurse Aide Evaluator Activity # N % Not Perform Activity % Perform Activity 31 Apply and monitor restraints 657 47.50% 52.50% 7 Assist client to fill out meal menu 652 40.60% 59.40% 51 Perform and record pulse oximetry 656 40.50% 59.50% 26 Perform cardiopulmonary resuscitation (CPR) 654 34.10% 65.90% 23 Clear foreign-body airway obstruction (FBAO) 648 30.10% 69.90%

18 Performance Ratings

19 Most Important Activities
Activity 1 Year or less NA Activity # N Avg. Import Std. err. 19 Follow Standard/Universal precautions (e.g., handwashing, personal protective equipment [PPE], isolation guidelines) 556 4.95 0.01 22 Apply and respond to client safety alarms 537 4.91 104 Report any suspected neglect, mistreatment or abuse 499 4.9 0.02 103 Report and record unusual incidents (e.g., errors, injuries, falls) 520 94 Follow Health Insurance Portability and Accountability Act (HIPAA) 519 4.87 Activity Nurse Aide Evaluator Activity # N Avg. Import Std. err. 19 Follow Standard/Universal precautions (e.g., handwashing, personal protective equipment [PPE], isolation guidelines) 660 4.93 0.01 104 Report any suspected neglect, mistreatment or abuse 635 4.91 103 Report and record unusual incidents (e.g., errors, injuries, falls) 632 4.85 0.02 22 Apply and respond to client safety alarms 628 4.84 94 Follow Health Insurance Portability and Accountability Act (HIPAA) 629 4.83

20 Least Important Activities
Activity 1 Year or less NA Activity # N Avg. Import Std. err. 5 Provide nail care 428 3.81 0.05 1 Provide foot care 418 3.83 7 Assist client to fill out meal menu 294 3.84 0.06 61 Assist or encourage family to help with client's care 4 18 Provide physical comfort measures (e.g., back rubs) 513 4.05 0.04 Activity Nurse Aide Evaluator Activity # N Avg. Import Std. err. 34 Assist nurse with dressing change 507 3.45 0.05 7 Assist client to fill out meal menu 387 3.58 0.06 61 Assist or encourage family to help with client's care 559 3.78 5 Provide nail care 602 3.79 0.04 58 Assist client with recreational activities 599 3.9

21 Mean Importance Ratings

22 Conclusions and Next Steps
Respondents found activities listed in the surveys to be representative of CNA work. Importance ratings given by CNAs and NAEs were similar. Results obtained from job analysis surveys were used to determine test plan and weighting of test plan areas.

23 2011 NNAAP Test Plan Specifications

24 Reports and Technical Briefs
NNAAP 2009 Job Analysis Report (available on NCSBN website this summer) 2011 NNAAP Test Plan Report is available for download at https://www.ncsbn.org/1721.htm

25 NNAAP Test Development Process
Job Analysis Content Outline Item Writing and Item Review Subject Matter Expert (SME) Panel Review Editorial Review Building Test Forms Setting the Passing Standard Pretesting of Items Administering Examinations

26 Standard Setting To determine a point on the ability continuum by which a candidate must exceed to be deemed competent Specific to the NNAAP examination, the goal of standard setting is to determine the level of nursing ability necessary for certified entry-level nurse aides to practice safely and effectively. Passing standard = passing score = cutscore

27 (con’t) Standard Setting
“Where the results of the standard-setting process have highly significant consequences those responsible for establishing the cut scores should be concerned that the process by which cut scores are determined be clearly documented and defensible.” (AERA/APA/NCME, Standards for Educational and Psychological Testing, 1999, p. 54)

28 Assumptions for Standard Setting
Certification and licensure is based on an assessment (usually an exam) that is content-valid, scalable and reliable. We can create a defensible process that can quantify "how much" knowledge or skill a person must have to be considered minimally competent.

29 Scores on NNAAP Exam Type of score is very important concept
Candidates either "pass" or "fail” their exams. The NNAAP uses a criterion-referenced standard setting process through the definition of minimally competent candidate. We are not asking which candidates were in the top XX% on the exam. We are only concerned with the pass or fail decision.

30 Importance of Standard Setting
Certification and licensure examinations are designed to: Protect the public from unsafe practitioners Ensure "best practices" of the profession Require entry-level professionals to achieve a minimal level of knowledge or skill in their field to perform their job safely and effectively.

31 (con’t) Importance of Standard Setting
If standard is set too low, we will certify some candidates who are unqualified. If standard is set too high, we will deny a certification to some candidates who are qualified or competent. Set appropriate standard while referencing the criterion. Briefly mention criterion  minimally competent candidates…

32 Important Caveats No “true” value exists
Policy decision, related to mission of organization (e.g., public protection) Standards should be revisited when test specifications, scope of practice/range of authorized duties, education programs, and/or other factors change

33 NNAAP Standard Setting Process
Overview of standard setting process SMEs discussed qualifications for entry-level NAs SMEs reviewed NNAAP content outline Training on standard setting methodology SMEs rated practice items SMEs provided round 1 ratings of actual items SMEs discussed round 1 ratings SMEs provided round 2 ratings Gather validity evidence Determine cutscore

34 Subject Matter Expert (SME) Panel
Representative of practice settings and specialties, regions Knowledgeable regarding practice analysis, test specifications All panelists are RNs with minimum of two years of nursing experience All panelists work with CNAs Ten SMEs served on the panel of judges

35 SME Panel Characteristics
# % NCSBN Geographic Area I 3 30% II 2 20% III IV Year of Post Licensure Experience 1 to 15 years 16 to 30 years 7 70% 31 to 45 years 1 10% Work Setting Nursing home Hospital Other long term care Certifications and Licenses Held (other than RN)* C NA 8 80% LPN/VN 4 40% * Several panelists hold multiple licenses and certifications.

36 The Minimally Competent Candidate
To establish a passing standard, we focus on the examinees that possess “just enough” knowledge, skills and ability to practice entry-level nursing safely and effectively We don't focus on high or low ability examinees We focus on those who are "on the fence"

37 The Minimally Competent Candidate
What distinguishes candidates with "just enough" knowledge, skills and ability from the other two groups? Knowledge/skill of the fundamentals Little advanced knowledge Have learned enough to move on (no remedial learning required) “Should” vs. “would”

38 Modified-Angoff Method
Rate how minimally competent entry-level CNAs would perform on each NNAAP item. Criterion-referenced Common in medical and health-related credentialing Vast research base, defensible Used in NCLEX-RN, NCLEX-PN, MACE and English proficiency standard setting workshops

39 Minimal Requirements for Entering the NA Profession
Training program is accepted by state boards of nursing and departments of health services Nurse aide has minimum 75 hours of class room training Nurse aide has minimum 16 hours of clinical training Nurse aide is at least 16 years old and in good mental health Nurse aide works in the following settings: long term care, acute care, assisted living or community health centers

40 Results from Standard Setting Workshop
Form and Round % Cut Score Raw Cut Score (60 item test) Standard Deviation Rating Reliability Form A Round 1 80.34% 48.20 (49) 0.004 0.81 Form B Round 1 81.34% 48.80 (49) 0.003 0.77 Form A Round 2 81.12% 48.67 (49) 0.79 Form B Round 2 81.87% 49.12 (50) 0.002 0.78 Note: Ratings from outlier were removed from the above results.

41 Panel Recommendations
SMEs reviewed results of standard setting workshop and their likely impact on NNAAP pass rate. Upon reviewing the information including SMEs’ own knowledge about the industry, all 10 SMEs agreed to a cut score of 47 out of 60 items. This new cut score will be implemented with the launch of 2011 NNAAP test forms.

42 Post-workshop Survey Rating Scale:
Question Mean Rating Standard Deviation Question 1: I understood the major goals of the standard setting workshop. 3.8 0.42 Question 2: I feel the training was adequate. Question 3: I feel that the discussion of the minimally competent nurse aide candidate was comprehensive. 3.9 0.32 Question 4: I understood the group consensus on a minimally competent nurse aide candidate. Question 5: I understood my task throughout the standard setting process. Question 6: I understood the Modified Angoff rating process. 3.4 0.52 Question 7: I understood the Beuk rating process. * 2.9 0.57 Question 8: I had sufficient time to reflect on my first rating. Question 9: I had sufficient time to reflect on my final rating. Question 10: I feel the group discussions were productive. 4.0 0.00 Question 11: I feel my opinion was considered. Question 12: I feel the passing standard recommended by the group was appropriate. Rating Scale: 1=Strongly disagree, 2=Disagree, 3=Agree, 4=Strongly agree

43 SME Feedback “I enjoyed the opportunity to meet other NA Educators from different states and be able to understand the variety of challenges each of us face. I feel honored to be a part of this process.” “Supportive, well informed group leaders, appreciative of our input, made the process understandable. I would gladly come back anytime.” “I learned a great deal about the process. I was very impressed with the professionalism and knowledge of the presenters. This is a very comprehensive process and I am honored to be a part of it.”

44 Next Steps 2011 NNAAP forms will be launched in January 1, 2011.
These test forms were constructed according to test specifications generated from the 2009 job analysis of nurse aides. All test forms were equated to be comparable in difficulty. Passing score for all 2011 test forms is 47 out of 60. A larger number of items will be pretested in 2011 to build NNAAP item pool. Next NNAAP item writing/review workshop will be hosted in March 2011

45 Reports and Technical Briefs
Test Plan Report – https://www.ncsbn.org/2011_NNAAP_Test_Plan-Test_Specifications_Report_links.pdf Standard Setting Report – complete report will be mailed to clients; proprietary information.

46 Questions?


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