1. 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

2. 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

3. 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

4. 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

5. Certification of Nursing Assistants
COMAR
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

6. 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

7. 7

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

9. 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

10. 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

11. 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

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

13. # 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. 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

35. 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

36. 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

37. #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

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. 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

45. 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

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

47. “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

48. Questions 48