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Passing the New NBCOT Exam

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[Background: In January 2009 the National Board for Certification in Occupational Therapy (NBCOT) revised its certification exam for occupational therapists (OTRs). For the first 1,100 first-time test takers (new graduates), the passing average fell to 73.7 percent, with a failure rate of 26.3 percent, according to a presentation given by Margaret Bent of NBCOT to OT program directors last spring. While scores have improved since, some concerns remain. Aware of all this, ADVANCE asked educator Rita Fleming-Castaldy, who is an expert on the exam process and effective exam preparation, to dispel rumors about how to take the new test and to offer study help.]

-ADVANCE editors

The revised NBCOT certification exam for occupational therapists has resulted in great anxiety among students, with many misperceptions being presented as reality. As the editor of an occupational therapy (OT) exam textbook1 nd an instructor for an exam preparation course,2I came to hear students and some educators repeat numerous rumors about the new test and observed students' trepidation about their abilities to pass this critical professional exam. In this article, I will repeat some of these inaccuracies and counter them with current information about the exam content, preparation, timing and scoring. While my audience for this article is students, OT educators also can use the information to dispel rumors about the exam and assuage students' test anxieties.

Content and Format

Rumors. "The exam has nothing to do with current practice." "NBCOT is revising the test due to the low pass rate." "My friend said the exam is all about." "The exams are harder in some locations."

Realities. NBCOT conducts periodic surveys of OT practitioners to ensure the content validity of the exam.3The knowledge gained from the practice analysis is used to create test specifications and construct the exam's blueprint. The current exam is based on the outcomes of a practice analysis conducted in 2007. The exam is only revised after NBCOT does an extensive review of these surveys. The exam is not revised based on pass rates.

Information gleaned from the practice analysis is used to guide the writing of exam items, which are written by occupational therapists who have completed item-writing training.4All items are reviewed by an independent professional testing agency and field-tested before they become scored items to ensure that they are clearly written, use current terminology and are unbiased, gender neutral and appropriate to diverse cultures. You will have to apply reasoning skills to determine the theme of exam items and your best answers. When asked, most students concur that the NBCOT exam content is intense but fair.

While students may perceive that the exam emphasized one practice area over another, this misconception is likely based on the reality that test takers tend to remember questions they struggle with, while quickly forgetting the ones easily answered. The items on the exam are different on each administration and are pulled from a pool of thousands of potential items. Therefore, the exam your friend completed is highly unlikely to be the same as yours. The NBCOT exam is not geographically determined.

Question Format

Rumors. "The new exam is drastically different." "The questions are written to 'trick' students." "The CS items use a decision-tree format."

Realities. The current OTR exam remains largely comprised of multiple choice (MC) items. These are the traditional, objective questions that you have likely answered for years. The MC items are comprised of a stem that addresses a specific aspect of OT, with one of four possible answers correct.5There are no combination answers (e.g., A and C) and no "all of the above" or "none of the above" answer choices for the MC items.

Currently, there are 170 MC items on the OTR exam as compared to the 200 MC items that were on past OTR exams.4The addition of three clinical simulation (CS) items is the major change to the NBCOT exam for OTRs.4,5

The CS problems are designed to simulate different situations that entry-level OTRs face in daily practice. They are comprised of an opening scene that presents a practice situation and three to six sections, each with further information and a question with multiple potential decisions/actions.5While these sections do progress in a logical fashion (e.g., from screening to evaluation to intervention), the CS items do not use a decision-tree format. Your answers in one section will not determine the questions or answer choices in subsequent sections.

But unlike the MC items, more than one option will be correct on the CS items. Once you select a decision/action on a CS item, a feedback box describes the outcome of the selection. This may be positive, negative or neutral, so you must use reasoning skills to determine the impact of your selection. You can use this information and your assessment of its meaning to inform your next answer, but you cannot use this feedback to reverse an answer. The CS format aims to replicate real practice situations, in which you cannot take back your decisions once they are made or actions once they are performed. However, in real life you can learn from the results of your decisions and actions, so on the exam you have the opportunity to use the provided feedback to select or reject other CS choices.1,2,5Consequently, one error will not set you onto a path towards exam failure.

Effective Preparation

Rumors. "If I did well in my OT program and on fieldwork, I do not have to study very much." "Rote memorization is all that is required to pass the exam." "My friend passed, and only studied the week before."

Realities. Students with solid histories of academic and fieldwork success have failed the NBCOT exam. I often meet these students at an exam preparation course that I am instructing after this initial failure. A common reason they give for their exam failures is inadequate preparation. While some may pass the NBCOT exam after using a "fly-by-the-seat-of-your-pants" approach, this is "clearly not the ideal."6If you take an organized, targeted approach to your exam preparation, the likelihood of passing the NBCOT exam on your first attempt will be greater.

There are many resources available to help you prepare. I suggest you discuss your options with newly certified occupational therapists whose opinions you trust (e.g., new hires on your fieldwork, recent graduates of your OT program) to assess which products will best meet your exam preparation needs. Peer feedback also can help you critique the usefulness and validity of the products available. Students consistently tell me that they save time and money by getting honest feedback from their peers and previewing the available products before they make an exam preparation purchase.

I have heard complaints that some products include no feedback on whether answers on practice exams were right or wrong, practice exams with "easy" questions and/or questions that are inconsistent with the NBCOT format, content reviews that include nonessential information (e.g., the history of OT) while not including information essential for exam success (e.g. environmental modifications), and publications with outdated information (e.g., the exam has 200 MC items) and/or bad advice (e.g., take an hour to answer the CS items).

Regardless of which resources you use to help you prepare for the exam, it is very important to know that there are three components to NBCOT exam success that must be addressed during your preparation. They are:

• accurate knowledge about the exam,

• mastery of the exam content, and

• self-awareness about your test-taking strengths and weaknesses.

When students tell me they were ill-prepared for the NBCOT exam, their lack of preparedness typically involves one, if not all, of these factors. Therefore, be certain your exam preparation tools provide comprehensive information about the new exam and the depth and breadth of OT.1,4Students report that using a repu-table comprehensive review textbook greatly eases preparation. A good review text will be based on sound OT references; you can refer to these if you are weak in a given area.

Finally, be sure your preparation includes an honest critique of your assets and limitations for success on the exam. This self-awareness is critical in order to individualize your preparation plan. You can develop and implement behavioral techniques that build effective test-taking habits and ameliorate ineffective ones.1,2

Answer Selection

Rumors. "C is the most common answer on MC items." "The most detailed answer choice is most likely correct." "I should select all options in the first section of a CS item to get feedback to help answer the next sections."

Realities. There is no easy formula for accurately answering items on the NBCOT exam. The exam emphasizes the analysis of practice situations and the application of knowledge and skills to a diversity of domain-specific tasks; therefore, select answers thoughtfully and judiciously. Use exam prep products that emphasize learning by doing by providing multiple chances to answer MC and CS items.

Managing Stress, Time

Rumors. "If I skip the tutorial(s), I can use this extra time for taking the test." "If I need a break, I can stop the exam." "If I have test anxiety, I can ask for more time as an accommodation." "Allot 20 minutes for each CS item."

Realities. Arrive 30-45 minutes before your scheduled exam administration time. This will enable you to calmly check in with the staff at the exam center.4You can get physically comfortable (e.g., move the computer screen to decrease glare, adjust the chair, take a bathroom break). You will be sitting for four hours, so don't underestimate the advantages of taking time to be comfortable.

Getting there early also allows you to take the CS tutorial in a relaxed manner. I advise all candidates to take this tutorial and the subsequent MC item tutorial for two reasons:

• The time you spend on the tutorial(s) before you begin each exam section does not count toward its administration time.

• NBCOT research has found that candidates who take the on-site exam tutorials score better on the exam.7

Once you begin each exam section, the time counts down. No time is allotted for breaks unless pre-arranged as an accommodation due to a disability or medical necessity. Test anxiety is not considered a disability. Spend about 10-12 minutes on each CS item and an average of one minute on each MC item. This pacing gives you a bank of 30-40 minutes to use when answering more challenging items. Answering the first sections of the exam in a timely manner will enable you to answer all of the exam items in the allotted four hours.

Exam Scoring

Rumors. "NBCOT scores the exam to keep a pre-determined pass rate." "If I pick a wrong answer on a CS item, I will go down a path that will make me fail." "Each item is worth a set number of points." "Once I get a certain number right or wrong, the exam shuts off." "If I mark too many items, I will lose points."

Realities. The NBCOT exam is criterion referenced, which means that your performance is compared to a pre-set standard. If you perform at or above this standard, you pass; perform below it, you fail. This standard does not change according to how many candidates pass or fail the exam.4,5The score is based on the accumulated weighted scores of all MC items and CS problems across domains.

The exam includes pre-test items that are not scored, intermixed with (and indistinguishable from) the scored operational items, so you must answer each item as if it counts.4,5The computer does not shut off after you have passed or failed, nor does it tell you anything about your performance. The CS items do not follow a decision-tree format, so a wrong selection will not automatically result in subsequent errors. Marking MC items has no influence on your score.

Preparing for a high-stakes examination such as NBCOT's is understandably stressful. It is also reasonable to feel restless to begin practicing your chosen profession. Harness this motivation to move yourself forward. Keep your "eye on the prize" of becoming a therapist. As an occupational therapist for more than 30 years, I cannot think of a more worthwhile outcome.

References available at

Rita Fleming-Castaldy, PhD, OT/L, FAOTA, is an assistant professor in the occupational therapy department at the University of Scranton in Pennsylvania. She is the editor of the National OT Certification Review and Study Guide, the National OT Assistant Certification Review and Study Guide, and the Occupational Therapy Certification Exam Course Manual and serves as an instructor and research-and-development consultant for TherapyEd, a major national occupational therapy exam preparation company. You can reach her at

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Something needs to change with this exam. It is not fair that we go through Grad school get masters degree and have huge loans to get stuck not passing the exam. I have been taking the exams couple of times and keep failing. I was great in classes and fieldwork. However, I cannot seem to pass this exam. My whole life is now hanging on passing this exam. It is not motivating me anymore after studying so hard and failing. Really thinking over why i went into this career if the passing rate is horrible.

Sonia SJuly 08, 2016
Piscataway, NJ

I failed the COTA nbcot exam and I was wondering if the exam is going to be the same for the second time OTA test takers.

Sally SteveFebruary 12, 2016

I graduated with a degree in OTA and I have taken the NBCOT 3 times now and I cannot seem to pass the exam. I am getting more and more discouraged each time. I have used study guides directly from NBCOT website, flash card system that they offered, practice quizzes, absolutely everything and yet I keep missing it. This past attempt I failed by one point, ONE POINT! Not only is this exam way too expensive for anyone who is in school or working a low income job, it is also too difficult with too high of expectations. I feel NBCOT needs to make another change.

Dyan December 26, 2014

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