Strategies Used To Improve NNAAP Exam Pass Rates For First Time Test Takers (theory content, skills and curriculum development) Pamela Ambush Burris, MSN, RN, FRE Director of Education and Licensure Maryland Board of Nursing

Background Information Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) Defined training and evaluation standards for nursing assistants Defined a set of national minimum standards and assess knowledge and performance of nursing assistants 2

The nursing assistant in nursing homes is known as a The Office of Health Care Quality (OHCQ) is a Maryland state agency that surveys the licensed nursing home where the geriatric nursing assistant works. OHCQ licenses the nursing home and certified the nursing assistant and the nursing assistant training programs since 1973. The nursing assistant in nursing homes is known as a Geriatric Nursing Assistant (GNA). 3

OHCQ transferred GNA in NH to the MBON In 1999, the Maryland Board Of Nursing (MBON) was given regulatory authority of all the nursing assistants: OHCQ transferred GNA in NH to the MBON Regulation of practice of all nursing assistants Included overseeing and approval of all certified nursing assistant training programs Certification of the nursing assistant and the geriatric nursing assistant 4

Certification of Nursing Assistants COMAR 10.39.01 Certification of Nursing Assistants Definition: Certified Nursing Assistant (CNA) means an individual regardless of title, who routinely performs nursing tasks delegated by a registered nurse (RN) or licensed practical nurse (LPN) for compensation. Areas of practice-hospital, ambulatory settings, primary health care providers offices. Cannot work in the licensed nursing home. 5

passes the GNA-competency examination; Geriatric Nursing Assistant (GNA) is certified as a CNA; passes the GNA-competency examination; completes the registration process and is listed on the Maryland Geriatric Nursing Assistant Registry (MGNAR); Areas of practice-same as CNA’s in addition to licensed nursing homes. 6

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1st Time Test Takers- Skills 2001 MD Pass Rate 1st Time Test Takers- Skills MBON Response 44%44ass 4444 44% 4444 8

Brainstorming Session To improve the pass rate for the 1st Time Test Takers of the NNAAP Exam candidates: Define the problems Identify resources Identify constraints or barriers Identify effective strategies 9

Generate information Community Meeting MBON, the CNA Community, the testing company, the training programs, OHCQ other stakeholders Purpose - to give updates and information on skill performance and discuss practice issues and CNA issues 10

Generate information Site Survey Visit of Certified Nursing Assistant Training Programs ensure compliance with state and federal standards ensure curriculum submitted and approved by the MBON is what is being taught evaluation due to low NNAAP pass rates visit the educational setting, visit the clinical setting interview personnel and students at facilities 11

Four Pieces Of The Puzzle Identified (Four Strategy Areas Identified) Theory Content Skills Curriculum Development Remediation 12

# 1 – Theory Content Delivery of the theory content (i.e. instructors reading directly from the book; aged, yellow lecture notes) Student engagement issues Creative instructors teaching strategies 13

Strategies To Improve Theory Content: Identified the training programs that provided 50% of the Maryland test takers, which accounted for 40% of the failures Ten programs identified, pass rate below the 40 percentile range for skills Four free-standing CNA-TP Graduated 215, 78 passed NNAAP skills = 36.3% Graduated 394, 168 passed NNAAP skills = 42.6% Graduated 484, 252 passed NNAAP skills = 52.1% 14

Strategies To Improve Theory Content: Four community colleges Graduated 638, 273 passed NNAAP skills = 42.8% Two long term care facilities Graduated 78, 39 passed NNAAP skills = 50% Instructors from these identified training programs attended mandatory faculty workshop focused on effective instructor teaching strategies Taught by peer instructors whose training programs were in the 90 percentile NNAAP pass rate 15

Strategies To Improve Theory Content: Effective instructor strategies taught: assessment for learning - students know at the beginning of a unit of study what they are expected to learn; lesson plan, course objectives, course syllabus 16

Strategies To Improve Theory Content: evaluation process -formative – information needed to adjust teaching and learning while the student is in the classroom environment, i.e. quizzes -summative – to determine if the student has met the course goals or learning outcomes at the end of the course, i.e. final examination 17

Strategies To Improve Theory Three Learning Styles Visual 65% of population (Dunn, 2000) Learn through seeing Sit in the front of the class observing body language and express of instructor Visual displays – diagrams, Power Point, handouts Take detailed notes 18

Strategies To Improve Theory Three Learning Styles Auditory 30% of population (Dunn, 2000) Learn through listening Focus on the tone of voice, pitch, and speed Verbal lectures, discussion groups, read information aloud, tape recorder 19

Strategies To Improve Theory Three Learning Styles Tactile, touching 5-15% of population (Dunn, 2000) Learn through movement and touching Hands on approach Writing on flip charts, case studies, simulation of tasks and skills 20

Strategies To Improve Theory Content: Student engagement Role play Case studies Discussion questions Peer instruction Peer tutoring Peer evaluation 21

Innovative Teaching Strategies Power point Games, i.e. medical terminology jeopardy Flashcards Simulation Case studies 22

Theory Content Summary Of the ten programs identified for low performance Two programs did not renew Five instructors (out of approximately thirty) did not return to the CNA training program to teach Skills pass rate on the NNAAP examination increased 23

#2 - Skills Maryland Geriatric Nursing Assistant Candidate Handbook Mock Skills Testing In-facility testing Sites 24

Maryland Geriatric Nursing Assistant Candidate Handbook NNAAP – Blue Book Maryland Geriatric Nursing Assistant Candidate Handbook Introduced to the class the first day Instructional guide for students from registration to skills testing Reference for GNA skills, testing information, and eligibility requirements 25

Mock Skills Demonstration Testing CNA-TP use as summative evaluation Prepares students for NNAAP Skills Exam testing Reduces students anxiety levels Increases students level of confidence Scenarios given and exercise is timed 26

Open skills laboratory for student practice Mock Skills Testing Practice of Skills Open skills laboratory for student practice Open skills laboratory with a dedicated instructor available Convenient hours for students utilization 27

Regional testing sites are located throughout the state of Maryland Testing Centers Regional testing sites are located throughout the state of Maryland Testing conducted once a month Schedule is posted a year in advance for candidate and facility reference In 2001, 9 regional testing sites In 2010, 6 regional testing sites 28

In-Facility Testing Centers Is a facility testing site that is located in a facility that conducts nurse assistant training programs Is a facility test site that is not open to nursing assistants that have completed a CNA training program at other facilities 29

In-Facility Testing Centers - Advantages Increases students confidence level Decreases students test anxiety Familiarity with testing site, equipment Convenient location Test date convenience **In-facility testing sites account for approximately 77% of the total candidate testing volume 30

In-Facility Testing Centers 0 in-facility testing sites In 2010 66 in-facility testing sites 31

#3 – Curriculum Development – Revisions Content Dated Content Relevant To Current Practice Content Experts Practice Resources Evidence Based Practice 32

Minimum 60 hours of theory Minimum 40 hours of clinical Curriculum Content Minimum 60 hours of theory Minimum 40 hours of clinical Instructor ratio in clinical 1:8 GNA- clinical must be in a licensed nursing home CNA-Training Programs approved for two years 33

Content Relevancy/Dated Inform Board of exploring currency based on evidence based practice of CNA-TP curriculum Content Experts/Practice Experts Include possible curriculum revisions Form a committee to discuss curriculum revisions 34

CNA Curriculum Revisions Committee Consists of representatives from various practice areas, i.e. Long term care, hospital, DDA Consists of representatives from varied CNA-TP categories, i.e. community colleges, freestanding programs, long term care facilities, DDA facilities Implemented Fall 2009 35

Theory content needs to be added Theory content needs to be enhanced Discussions Theory content needs to be added Theory content needs to be enhanced Minimal number of hours for theory and clinical needs to be increased Complexity and acuity of the scope of practice for the CNA has changed Include technology in CNA scope of practice 36

#4 – Remediation Regulations permit the MBON to withdraw approval from any program whose graduates achieve less than 90% of the national success rate on the National Nurse Aide Assessment Program (NNAAP) examination. 37

In 2005, the MBON approved the CNA Training Program Remedial Plan Submission. This plan requires those CNA Training Programs whose annual pass rates on the NNAAP examination are below the state mandated percentages to submit a remedial plan for improvement to the Board for approval. 38

Program Areas Addressed In The Remedial Plan Student Population Address ways in which comprehension of language and appropriate level at which the course content has been written. Areas tested include proficiency in English, reading, and mathematics. Teaching Strategies Address how the information is disseminated to the student. What type of materials and technology are utilization in the classroom. 39

Program Areas Addressed In The Remedial Plan Skills Lab The equipment functions properly and adequate supplies for students. The training program has an “open” lab for students to practice. 4. Faculty New instructors receive extensive orientation and are mentored. All aspects of the program, teaching resources, teaching methodology, regulations, are thoroughly addressed. 40

Program Areas Addressed In The Remedial Plan 5. Clinical Setting Address how the students are oriented in the clinical area Preparation of graduates for success of NNAAP examination What type of evaluation process is implemented? How are graduates prepared for success on the NNAAP exam? 41

Remediation Plan 1st year placed on remediation plan, monitored, site visit, self-analysis report submitted to MBON 2nd year CNA-TP must obtain a nurse consultant, approved by MBON 3rd year MBON may close the program – no program has gotten to this level yet, the program has either improved or voluntarily closed 42

Ownership Of Training Program Posting of CNA-Training Programs written and skills NNAAP Pass Rates on MBON’s website in ranking order. 43

Where Are We Now? Continue Annual Informational Meetings between MBON, OHCQ, CNA training programs, testing company, vending company and stakeholders for the disseminated and exchange of accurate and current information. In 2009, in addition to annual informational meeting, a four-hour effective teaching strategies for all training programs was held. In 2010, four-hour session is planned on English as a second language (ESL). 44

Where Are We Now? Continue to monitor CNA training programs for competency Continue yearly site visits Continue to monitor programs on remediation plan, NNAAP written and skills pass rates Continue to encourage in-facility testing Continue to strive for a pass rate of 90% on the NNAAP Skills examination 45

Conclusion Identified the four strategies that have been effective for program improvement Team effort between MBON, the CNA-TP, and the primary stakeholders 46

“The road to success is always under construction” Skills Pass Rate 2009 1st Time Test Takers 87.6% “The road to success is always under construction” 47

Questions 48