Your best student – the one who showed up in the practice lab and seemed determined to pass the test, the one you had complete confidence in, the one who you KNEW was going to make a fantastic CNA – FAILED the skills exam. 

Why? How? What could have possibly happened?

The Skills part of the state exam is challenging – for both students and instructors. This article should help clear up the mystery around skills testing and give you tips to better prepare your students for test day.

The care plan, the whole care plan & nothing but the care plan.

Patricia Laramee, RN - 4YourCNA Tweet
care plan foundation

The Foundation

So, we all know that CNAs follow the care plan. And you have probably said something like this in class. 

Once or twice. Then you moved on to medical terminology, body systems, healthcare team members and all the other things your curriculum dictates. Even CNA Textbook authors barely touch on the care plan in CNA textbooks – take a minute to look it up in the appendix of your textbook. In most CNA textbooks, the Care Plan is given just one or two paragraphs – out of the entire book.

When you finally get around to learning skills, you may just assume that they remember what a care plan is and how it is there to direct care for each individual patient. But, we often don’t really use the care plan as the foundation of the rest of our instruction. And, since it is the foundation of what a CNA DOES, it should really be the foundation of what a CNA LEARNS.

So, if Care Plans exist to direct the care of each specific patient, and they are all a little different because the patients are all a little different, then it is important to get students to understand this concept completely. 

As nurses, we know this…but we probably don’t think about it in terms of the CNA.

The simple truth is that CNAs cannot do ANYTHING that is not on the care plan. They can’t brush that patient’s teeth. They can’t help that patient to the bathroom. They can’t give a bedbath to a bedbound patient. They can’t do ANYTHING without it being on a care plan or delegated by a nurse. Because to do something independently requires decision making skills (“I think that patient needs…”). And decision making employs judgment – which is ALWAYS a nursing function, according to state statutes. So, what does this mean? Your CNA students have to be trained to follow that care plan…exactly. From day one.

So, as you demonstrate every single skill, review every patient encounter, give every body system lecture, and assign every project – they all need to refer back to the care plan. If the care plan is the foundation, it should be present throughout the entire program.

If you are teaching about feeding a patient, you would want to have them refer to the care plan for specific instructions,  such as:

  • using plastic utensils instead of metal for patients undergoing chemo
  • delivering food to one side of the mouth due to post-CVA paralysis or weakness
  • do not use dentures while feeding due to severe thrush infection
  • thicken all liquids to honey-like consistency due to moderate dysphagia
  • maintain strict adherence to feeding schedule due to scheduled insulin administration
  • encourage intake of calcium-rich foods during meals and snack selections due to osteopenia
  • prop patient in an upright position with pillows and positioning devices prior to feeding due to severe spinal deformity
  • encourage socialization and interaction during feeding due to depressive anorexia

…and that list could go on and on. The specific accommodations that each patient may need with such a simple task is literally endless. And these accommodations must come from the nurse – not the CNA. You can’t possibly teach all of these possible accommodations – for all possible conditions – during every possible skill – in the time that you have. It pays to go over a few of them, but always in context of the care plan!

Your students will often start these off for you, by asking “What if…” questions. What if the patient can’t chew? What if they are allergic to applesauce? What if they can’t sit up straight? What if they don’t want to eat? What if…? Your answer should always include, “What does the care plan say?”. Giving them a very specific accommodation based on their question will lead them to believe that one accommodation will work for everyone – and we all know it won’t. Students must be referred back to the care plan (or the nurse) to learn more about this particular patient. This is essential in preparing students for the clinical world. Because if you don’t give them a tool to use when you are no longer around, they will try to make decisions – thinking that they are supposed to have all the answers.

So, if you want your students to be successful – stop answering questions directly and teach them to rely on the care plan (or their nurse).

This is so important on the skills exam! Because most of the skills grade will depend on whether they followed that testing care plan. EXACTLY. If the care plan tells them to exercise the left shoulder… that is the ONLY thing they should exercise. If the care plan tells them to dress the resident in long sleeves, then choosing a short-sleeved option is not appropriate (no matter how hot it is). If the care plan tells them to count the pulse for one full minute – they need to count for one FULL minute. You either follow the care plan EXACTLY as it is written – or you report to the nurse why you can’t. This is an essential part of the state skills exam. So, don’t train them to follow what they see in a video, because no matter how good that video is, it does not tell them anything about THIS patient. Train them to follow the care plan and they will ALWAYS get it right!

Now that you understand the foundation…let’s go on to review the type of tasks a CNA will do – and it probably isn’t what you think!


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