How to Pass Your Anesthesia Boards

Preparing for the NBCRNA National Certification Exam (NCE) can feel daunting, but it doesn’t have to.

Even at the graduate level, anesthesia students sabotage their success by practicing ineffective and outdated study strategies. This cascades into feelings of overwhelm, frustration, and burnout. It also explains why it feels like you must study all the time.

In 2023, first-time candidates achieved an 83.2% pass rate on the NCE. We want to help you be among those.

We’ll empower you to become a super learner, so you can pass the CRNA boards and become a distinguished Certified Registered Nursing Anesthetist. Print this article, grab your multi-colored highlighters, and toss them in the trash. We’ll explain why in Myth #4. Let’s do this.

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Table of Contents:

1. A mental model for learning
2. Myth #1: Multitasking boosts productivity
3. Myth #2: I don’t have enough time
4. Myth #3: Cramming for a week or two is all it takes to pass the NCE
5. Myth #4: I know this already because I’ve seen it a thousand times
6. Myth #5: I should focus on one subject at a time
7. Myth #6: Textbooks should be read linearly
8. Myth #7: Everyone passes the NCE in 100 questions, so I will too
9. Bonus Myth: You can earn CRNA CE credits as a student

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A mental model for learning

Without following Alice down the rabbit hole of learning theory, let’s walk through a simple mental model that gives you the fundamentals you need to know.

You perceive your environment through your senses. Afferent pathways relay sensed information to your brain, where the information is placed into a sensory store (think of a bucket).

Attention is the process of transferring information from a sensory store to your short-term memory. Most sensory information is filtered out before you become aware of it.

Attention is a limited resource, and maintaining it requires effort. You can’t pay attention to all things at all times, so you must choose where to focus your attention. And no, the human attention span isn’t the same as a goldfish (you can binge Netflix for hours, right?). The goldfish myth originates from misinterpreted research related to internet browser use.

Your short-term memory is where your conscious mind lives. It’s a limited resource that’s easy to overload. Excessive cognitive load can overwhelm your short-term memory capacity, hindering your ability to learn.

You must rehearse information to keep it in your short-term memory, otherwise, it disappears. Rehearsal alone is unlikely to build long-term memory.

Elaboration pushes information into your long-term memory. It occurs when you connect a new piece of information to something you already know. The more you process something, the more likely you’ll remember it.

Retrieval extracts information from your long-term memory and delivers it to your conscious mind. You can apply retrieved information to perform an action, such as answering a question on an exam.

Now that you’ve mastered the lingo let’s unpack the myths that will sabotage your success as you prepare for the NCE and learn what to do instead.

Myth #1: Multitasking boosts productivity

Multitasking is a poison pill for your focus.

When you think you’re multitasking, you aren’t really doing two things simultaneously. Instead, you’re rapidly switching between tasks. This is known as context switching.

Don’t believe us? Calculate the alveolar gas equation while singing a song (no, singing the calculation doesn’t count). At any second, you’re either thinking about the math or the song but never both at the same time. This is normal. Humans are monotaskers by nature.

When switching from one context to the next, your brain adjusts to the needs of the new task. It should make sense that checking email activates different cognitive processes than memorizing the coagulation cascade.

Your brain can’t switch between tasks instantaneously. Instead, when you move to task B, your brain stays partially focused on task A. This creates attention residue, which explains why it can take up to 20 minutes (or more) to become totally immersed in your work when you redirect your attention from one task to another.

Context switching is a tax you pay on your focus. But unlike the money you owe Uncle Sam, you’re in complete control of the tax you pay on your focus.

How much does context switching cost you in a day? What about a week or a year? When you want to check Instagram during your next study session, ask yourself if it’s worth the cost. Those expenses add up fast!

Do this instead → Monotask

These tactics will help you overcome context switching so you can learn more in less time.

Pomodoro technique

Pomodoro means “little tomato” in Italian. Don’t let the name fool you; this technique can help you achieve massive success in your studies.

A pomodoro consists of periods of intense focus followed by short breaks. Let’s break it down step-by-step:

1. Establish how long each pomodoro will last. Each one should last between 30 and 60 minutes (we like 60 min in most cases).
   • 60 min pomodoro = 50 min of distraction-free studying + 10 min break
   • 30 min pomodoro = 25 min of distraction-free studying + 5 min break
2. Determine how many pomodoro fit into your time block. Let’s say you have a 4-hour time block:
   • 60 min pomodoro / 4 hrs = 4 pomodoros
   • 30 min pomodoro / 4 hrs = 8 pomodoros
   • After every 4th break, take a longer break of 15 – 30 minutes.
3. Decide what you want to study during each pomodoro.
   • Allocate time for learning new content as well as time for retrieval practice (discussed below).
4. Set the timer, and get to work:
   • When you’re learning, you’re not doing anything else.
   • When you’re on break, you’re not thinking about learning.

Own your attention

It’s ok to disconnect for a little while. When one exam stands between you and your dream of becoming a CRNA, it’s wise to restrict (or even eliminate) your social media and news consumption. These digital platforms, as well as the notifications on your devices, are engineered to hijack your attention.

Use an app like RescueTime to block distractions. You can also take inventory of how you’re using your time. The results may surprise you.

Silence sounds and notifications on your electronic devices. When enabling “Do not disturb,” you can customize it to your schedule and allow calls only from favorites (significant other, child’s school, etc.). Here’s how:

• iPhone and iPad
• Mac 
• Android 

What about music? Soft background music can help you focus and block out distracting noises. If you want a playlist that aligns with your pomodoro session, you can search 50/10 and 25/5 playlists on YouTube. Here are a few examples:

• 50/10 Slow jazz
• 25/5 Lo-fi

Myth #2: I don’t have enough time

Everyone has the same 24 hours in a day, but not everyone has the same obligations during those 24 hours. Regardless of your commitments, asking where to find more time might be asking the wrong question.

Do this instead → Own your time

While you can’t magically add hours to the day, you can optimize the time you already have.

Make a PACT to achieve your goals

Success doesn’t happen by mistake. You need a roadmap with clear goals to direct you to your final destination. Committing to your goals ahead of time will help you stay accountable. It’s even better if you join a group of classmates that hold each other accountable.

Let’s say your goal is, “I will pass the NCE.” It’s a good start, but it’s missing several critical elements that a goal should have.

We like the PACT goal-setting framework. 

• Purposeful:Your goal is motivating because it aligns with your long-term objectives.
• Actionable:Your goal is based on an output within your sphere of control.
• Continuous:Your goal is realistic, and you can follow through on your plan without a significant risk of burnout.
• Trackable:You can easily track progress by saying, “yes, I did this” or “no, I didn’t do it.”

Let’s apply the PACT framework to revise our goal: “I will dedicate 25 hours per week to complete a comprehensive, 12-week study plan, so that I will pass the NCE.”

• Is it purposeful? Yes. This goal will help you achieve your dream of becoming a CRNA.
• Is it actionable? Yes. you can control how you allocate and prioritize your time to study.
• Is it continuous? Yes. It’s a realistic goal that you can execute without the risk of burnout.
• Is it trackable? Yes. Using your calendar, you can mark each session as complete or incomplete (yes/no).

Take control of your schedule

Steven Covey says, “Begin with the end in mind.” This means you need to visualize success and then work backward to develop a plan to take you across the finish line.

We tend to overestimate what we can do in a day but underestimate what we can accomplish in a year.

Think of your time in blocks. Block time for your classes, OR schedule, studying, family/friends, sleep, and time off (yes, you need to schedule time off). If you don’t intentionally and aggressively guard your time, life will get in the way of achieving your goals.

With your goal in hand, the next step is to work backward to design your study plan (or use one of ours). Staying with our 12-week example, you’ll map each week of your plan to your calendar. Don’t skip this step!

Label each week as a milestone, and list the subgoals needed to achieve your milestone for each week. When you’re done, ask yourself, “Is this plan realistic?” If not, you’ll need to cut other commitments, extend your study plan, or accept your time limitation and prioritize what you need to learn (we don’t love this option). Be honest with yourself, and build in time for unexpected obstacles that will pop up along the way.

Preview your subgoals at the beginning of each week to remind yourself what’s most important. At the end of each week, evaluate your progress against these subgoals. What worked? What didn’t? What changes do you need to make to stay on track?

Myth #3: Cramming for a week or two is all it takes to pass the NCE

Everyone crams sometimes. Maybe you’ve done it for every exam throughout anesthesia school? Why fix what isn’t broken?

On the surface, massed practice (a.k.a. cramming) feels like it works. Why? It supports short-term memory, which can help you earn an “A” on tomorrow’s exam. When behavior is positively reinforced, there’s little motivation to change that behavior.

Doesn’t earning an “A” mean you mastered the content? Not necessarily. Letter grades assess knowledge at a single point in time. This doesn’t mean you’ll know it forever. What good is an “A” on your crisis management exam if you can’t recall how to treat a pulmonary embolism during a total knee arthroplasty?

You don’t study to pass the test. You study to prepare for the day when YOU are the only thing standing between the patient and the grave.

Here’s the rub. Information learned through massed practice is shallow and short-lived because it fails to push information into long-term memory effectively.

Do this instead → Spaced practice

You’ll improve long-term recall when you space out your learning and refresh concepts over time. We call this spaced practice or spaced repetition. Let’s look at an example that shows 90 minutes of studying with spaced practice vs. 90 minutes of studying with massed practice. You’ll get more mileage from the spaced practice approach.

Let’s look at the forgetting curve and the learning curve. Here are the key takeaways:

1. Forgetting curve: We forget the things we don’t take time to review.
2. Learning curve: We retain more of what we learn by reviewing it periodically over time.

How long do we retain what we learn? Here’s the data from the original research. Don’t focus on the specific numbers, but rather use the trend to inform your conceptual understanding of learning and long-term memory.

• Immediately = 100%
• 20 minutes = 58%
• 1 hour = 44%
• 6 days = 25%
• 1 month = 21%

What’s the best way to review previously learned material? Spoiler alert, it’s not obsessively reviewing your notes or re-reading the textbook chapter, it’s retrieval practice!

Retrieval practice requires that you recall learned material without seeing it in front of you. It’s like building muscle memory for your brain. By forcing your brain to retrieve information, you’re pushing yourself up the learning curve. Do this enough times, and brachial plexus anatomy will be as easy to remember as your email address.

For many students, retrieval practice causes frustration because it feels harder. But that’s precisely why it works! Challenging your brain in this way strengthens the neural connections that support long-term memory.

If you’re planning your schedule in advance, it’s easy to incorporate spaced practice into your time blocks and pomodoros. Here’s how to incorporate retrieval practice into your study sessions (APEX uses all of them):

• Board-type practice questions
• Flashcards
• Writing prompts
• Mind maps

Myth #4: I know this already because I’ve seen it a thousand times

Have you ever reviewed your notes so many times that you believed you mastered the subject? After all, you understood everything you read and highlighted all the important concepts. Then you took an APEX review exam, but your score was lower than you expected. What happened?

Humans are poor judges of their own knowledge. Students with a superficial understanding of a subject tend to overestimate their knowledge. This is an example of the Dunning Kruger Effect. In the context of board prep, the problem isn’t what you don’t know (that’s easily solved by studying). The real problem is not knowing what you don’t know.

Passive learning techniques (e.g., re-reading highlighted notes over and over) trick you into thinking you know more than you do. This is called the illusion of knowledge. Just because you recognize information when you read it doesn’t mean you truly know it.

Do this instead → Feynman technique

How can you distinguish between the illusion of knowledge and true mastery? We like the Feynman technique (it’s another form of retrieval practice). Let’s break it down step-by-step with an example.

1. Choose a concept to learn.
   1. We’ll use neuromuscular transmission in this example.
2. Teach it.
   1. Write or speak each step of the process as if you’re explaining it to someone else. Mind maps, sketches, and other visual aids are helpful, too.
   2. Start by describing how the action potential propagates along the alpha motor neuron and end by discussing calcium removal from the myocyte’s cytoplasm.
3. If you get stuck, return to your source.
   1. Getting stuck means you found a knowledge gap.
   2. Return to your source to relearn the material (e.g., textbook, class notes, APEX, etc.).
   3. Return to step 2, and try again.
4. Simplify the concept further.
   1. Try to reduce the complexity so that a high school student could understand it (i.e., describe it in plain English).
   2. Think you’re done? Would you stand in front of your class and teach the subject to your professors? If not, you have some work to do.

Myth #5: I should focus on one subject at a time

Most students study one topic at a time before moving to the next. This is called blocked practice (not to be confused with time blocking). While blocked practice may feel intuitive, there’s a better way.

Do this instead → Interleaving

Interleaving is the process of switching between subjects or topics as you study. Let’s say you have 3 hours and want to study the anesthesia machine, inhaled anesthetics, and malignant hyperthermia. You’ll divide each hour into 2 pomodoros (6 pomodoros in total).

1. Anesthesia machine = pomodoro 1 & 5
2. Inhaled anesthetics = pomodoro 2 & 4
3. Malignant hyperthermia = pomodoro 3 & 6

Why does interleaving promote long-term memory? It doesn’t allow you to access rote responses from short-term memory. Your brain must work harder to retrieve information because it’s constantly pulling from different subjects and topics. This helps you connect the dots between ideas, building stronger connections through deeper understanding.

You may be wondering if interleaving is a form of context switching? It’s not. The context (studying) is the same.

Myth #6: Textbooks should be read linearly

If you’re like most students, you start on the first page and stop at the last. When you’re finally done you ask, “What did I just read?” Approaching content in this way causes you to miss the proverbial forest for the trees.

Do this instead → Actively engage with your reading

SQ4R method

We like the SQ4R method with a slight twist:

S = Survey

• Scan the chapter to get a 30,000 ft. understanding of what you’ll learn.
• Imagine standing on a mountain looking down at the forest before you try to navigate through it.
• In this step, you’re building a scaffold in your mind, and you’ll fill in the details when you read the chapter.

Q = Question

• Formulate questions you expect to answer as you read.

R1 = Read

• Take notes to summarize the key concepts and facts.
• Be mindful not to slip into autopilot as you read.

R2 = Recite

• After each section, paraphrase what you read in your mind or out loud.
• This works to transfer understanding to long-term memory, and it also helps you gauge how well you understood what you read.

R3 = Relate

• Ask yourself how the material relates to other things you know.
• For instance, if you read that etomidate inhibits 11-beta-hydroxylase, take a moment to recall what you know about steroid synthesis in the adrenal medulla (retrieval practice).
• Ask yourself how the content relates to a recent patient. If you can’t draw on direct experience, create a scenario and apply the concepts to a fictitious patient.

R4 = Rewrite

• One of the best ways to learn lots of new information is to write it down (notes, flashcards, worksheets).
• The key is to summarize in your own words. Don’t mindlessly copy what’s on the page in front of you.
• We’re sorry to report that copying and pasting into your note-taking app won’t miraculously transfer the information into your brain. You need to do the work.
• APEX has over 800 workbook pages to help you.
• Alternatively, you can use the Cornell note-taking method.

Cornell notes

What makes the best notes? Fancy colors? Perfect handwriting? What about cute doodles of cats intubating other cats?

Above all, notes must be useful. They must help you learn AFTER you’re done writing them.

Ferociously transcribing everything your professor says or rewriting an APEX tutorial verbatim is pointless. These things pull you away from what you’re learning. Instead, it’s better to follow a structured framework that encourages you to be present in the moment AND helps you reinforce that learning afterward.

We think the Cornell Note-Taking system fits the bill. Divide your paper into four sections:

1. Title: This one is obvious.
2. Cues: List the main ideas and key questions.
3. Notes: Add keywords/phrases, bullet points, formulas, images, etc.
4. Summary: Summarize your notes after class or after reading. This forces you to reprocess the information and distill the most essential concepts.

When you return to your notes later, you should be able to cover the notes section and use the cues to quiz yourself.

Myth #7: Everyone passes the NCE in 100 questions, so I will too

When you take the NCE, confidence and mindset are as vital as content mastery.⁣

Between social media and talking to classmates, you’ll see lots of students who pass the NCE in 100 questions. This doesn’t represent all students. The truth is that people freely celebrate their wins, but they’re often reluctant to share their failures. When was the last time you saw an Instagram post where someone failed the NCE?

Do this instead → Prepare for all NCE questions

The NCE is a variable-length exam with anywhere from 100-170 questions. It’s likely your exam won’t end at 100 questions. Here’s what you need to know (based on NBCRNA 2023 data):

• First-time test-takers have a pass rate of 83.4%.
• If you need to repeat the NCE (due to first-time failure), the pass rate drops to 60.8%.
• Only 54% of students pass in 100 questions.⁣⁣
• Nearly 20% of all test-takers receive 170 questions (the maximum).
• 64% of students who take all 170 questions pass the NCE, so don’t give up!

If your exam continues beyond 100 questions, you’re not alone. The algorithm compares your performance to the passing standard with each subsequent question, so don’t give up! Whether you’re on Q101 or Q170, the odds of passing are ALWAYS in your favor.

Our best advice is to mentally prepare to take 170 questions. If you receive less, it’ll come as a pleasant surprise. ⁣⁣When students only expect 100, many deteriorate when they receive more. Mindset is the name of the game.

You can prepare yourself by leveraging our NCE/SEE practice questions through a SmartBank add-on subscription to our Student Review course. Not only would it give you experience with NCE-style questions, you can also build your question-taking stamina by creating practice tests with 170 questions.

If you don’t pass the NCE, let us know ASAP! While you’ll have 8 attempts to pass the NCE, you can only use 4 in the first year. Don’t paint yourself into a corner by exhausting multiple attempts before contacting us. We’ll schedule a free strategy session, where we’ll help you formulate a plan for success.

Bonus Myth: You can earn CRNA CE credits as a student

While this won’t help you pass the NCE, it’s relevant as you spend endless hours preparing for boards.

We receive this question frequently, but the answer is in the name of the CRNA recertification process: Continued Professional Certification Program (CPC Program). You simply can’t “continue” your professional certification if you haven’t earned it yet! This applies to all components of the CPC Program, including Class A and Class B credits.

Do this instead → Use APEX for continuing education

After you become a CRNA, you must recertify every four years. Just like we had your back for boards, we also have everything you need for recertification in one place. We’ll even give you a loyalty discount when you come back to us.

As a next step, learn everything you need to know about the CPC Program.

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Your action plan

Don’t feel pressured to implement everything at once. Understand that it may feel like more work at the outset, but chances are you’re learning more than you realize.

1. Map your semester on your calendar, and make sure you can reasonably accomplish your goals (professional and personal) in the time you have. Give yourself margin for the unexpected.
2. Pick two study tactics to start using today. Once they become part of your routine, add in others for a synergistic effect.

Do you have a plan to prepare for the NCE and SEE? We’ve helped thousands of students achieve their dream of being CRNAs, and we can help you too! Check out our Student Review course (online) and Boards Bootcamp (live).

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Updated 3/18/2024