When I found out that I did not pass the NBCOT® Exam, I felt as lost as I felt depressed. Where do I start and how should I tackle the material differently to ensure success the second time around? How can I study smarter, not harder? Whenever I sought counsel or advice, all I was ever told was to “increase my clinical reasoning skills” and to “apply my knowledge.” Okay… But what does that mean? What’s “clinical reasoning” and what are some practical strategies or concrete steps I can take to improve my ability to apply my knowledge clinically? So began my desperate search to find the answers and after many months of hard work, practice and trial and error, I finally learned how to study smarter, learn better and retain faster. In this article, I will combine my knowledge of everything I have learned from personal experiences as well as all the best insights I’ve gathered from the How Others Passed section to bring you 8 effective tips and strategies to master the NBCOT® Exam. If this is not your first attempt, be sure to also check out How I Went From 422 to 488. 

1. Practice Practice Practice

Study Smarter Not HarderDo as many practice exam questions as you can, as often as possible, using as many resources as you have available. Otherwise, you’ll end up recycling through the same old questions and memorizing the correct answers instead of applying your critical thinking skills and test taking strategies to derive the best answer choice. To ensure you have access to a wide variety and number of practice exam questions, you may want to consider purchasing more than one exam prep book, especially if this is not your first attempt. 


Consider doing at least 3 simulated practice exams before the actual exam day to build your stamina and focus. You can start with shorter exams in the first week and gradually build up to 4 hours in an environment that mimics the Prometric testing center.

Use a countdown timer for your practice runs – not a clock. On the day of the exam, you won’t be allowed to even wear a watch. You’ll have a countdown timer at the top right of your screen. I realized too late during my prep that this would be the case. It was a bit disorienting for me during the test to do reverse calculations to track how many minutes had passed with how many questions I had completed.

Meenadchi Gunanayagam

2. Identify the Actual Question

Before selecting your answer choice, be sure to identify the sentence that contains the actual question you need to answer. It’s easy to get lost in the sea of information provided and you may end up reading too much into the question. So be sure to get in the habit of identifying what the actual question is and make sure you’ve answered the question before selecting your final answer choice.

3. Dissect and Deconstruct

  • Safe – Consider all the precautions, contraindications, acuity of condition, population and age. 
  • Ethical – Is it Beneficial? Honest? Learn more with my Code of Ethics Video.
  • Client-Centered – Does your action respect the client’s desires, needs, religion and culture? 
  • Skilled – Remember that the services you provide will be as a licensed and trained practitioner. Therefore, your answer choice should reflect a response that is SKILLED, whether in observation, assessment or intervention.
  • Active – An answer choice that contains a specific action towards a measurable goal is better than a passive or vague action. For example, “perform safe and independent transfers using a transfer sliding board” is more of an active, measurable intervention and therefore a better choice than “avoid unsafe transfers during bed mobility.” 

If the question describes a scenario in which you have just completed an initial screening and you are asked to choose the NEXT best action, it is unlikely that the correct answer choice will contain intervention strategies or discharge planning because you haven’t done the evaluation or set treatment goals. So always think about the different phases of the OT process and choose an answer that is appropriate to where you are in the delivery of care. Learn more by watching my Occupational Therapy Process video. 

Example 1: Using a Biomechanical Approach

If you have a client with a hand injury in an outpatient hand therapy setting, you would most likely utilize a Biomechanical Frame of Reference that emphasizes the reduction of physical deficits in order to restore and remediate. Possible intervention strategies may include splinting, strengthening and ROM exercises and physical agent modalities.

Example 2: Using a Rehabilitative Approach

If you have a client with a spinal cord injury (SCI), you would recognize that recovery may not be possible and utilize a Rehabilitative Frame of Reference to adapt and compensate to maximize independence. So in the case with a SCI, remediation of deficits may not be the focus. Rather, the client may be offered adaptive strategies, tools and equipment to utilize their remaining strengths and abilities (Environmental Control Unit for communication, universal cuff for self feeding, transfer board for transfers, etc).

4. Stay with Problems Longer

Study Smarter Quote by Einstein

You will come across challenging questions that baffle you as much as they frustrate you. But these are opportunities for you to really hone your critical thinking skills and enhance your clinical reasoning. Instead of trying to go through as many practice exam questions as quickly possible, focus instead on really mastering each and every question before you move on. Wrestle with every problem until you have a mental breakthrough and resist the temptation to seek quick and easy answers from friends or social media. Be resourceful and diligent by doing your own research and giving your best effort to answer the question before seeking help. It is in this very grueling process of deriving the correct answer that you will develop the critical thinking skills necessary to apply your knowledge and successfully pass the exam.

It’s not that I’m so smart, it’s just that I stay with problems longer.

Albert Einstein

5. Use Immediate Feedback

When I was doing practice exam questions in preparation for the NBCOT® exam, I checked my answers right away instead of working through 30-50 questions and checking them after. The only exception to this was when I was doing a timed, simulated exam, in which case I forced myself to finish the entire exam before checking the answers. I used the immediate feedback approach for two reasons: 

1) I often forgot my own clinical reasoning and rationale by the time I came back to question 1 to review my answers; 

2) By the time I was done answering 50+ questions, I was mentally and physically drained and often didn’t have the motivation or energy to go back and check all my answers. This was problematic because I ended up remembering the answer choice that I had selected, regardless of whether or not it was the correct answer. 

While this approach may not work for you, it is something to consider if you’re having trouble remembering the rationales or want to avoid retaining the incorrect answers that you previously selected. 

6. Use Your Textbooks

Study prep guides are like CliffsNotes – great for a broad overview, but insufficient in providing in-depth knowledge and conceptualization. So whenever you’re feeling stuck or confused, open up your textbook. This will go a long way in helping you conceptualize the material and fill in the knowledge gaps. I personally relied heavily on the Pedretti’s Occupational Therapy 7th Edition & Occupational Therapy for Children by Case-Smith.

7. Teach it to Learn it

Study Smarter Not HarderResearch shows that teaching someone is one of the most effective ways to understand the material, recall it more accurately and apply it more effectively. In fact, if you can’t explain the concepts in simple terms to someone else, you probably haven’t truly conceptualized it. So enlist the support of your family, friends, study buddies, or a teddy bear if you must, to practice teaching the material until you can articulate and convey the concepts in layman’s terms.

8. Learn from Others

Be sure to explore all the existing resources and tools on the OT Miri website. For one, the How Others Passed section is a great place to start because you can read other people’s experiences, tips and strategies that helped them successfully pass the board exam. Many of these posts are as insightful as they are inspirational and I am certain you will walk away from these posts feeling both encouraged and empowered.

Above all, and most importantly, believe in yourself. No single person, guru or tutor can help you as much as you can help yourself and the best way to do that is to believe in your potential. We are our own harshest critic and all too often, we allow the negative voices to consume our mind and heart. But during this time, I want to challenge and encourage you to guard your heart against the voice of negativity and fill it with powerful words and voices that validate your sense of worth. The fact that you’re at this point in your life, preparing for the board, is already a testament to your intelligence, capacity and potential. So please don’t let this exam waver your sense of confidence and competence. No one and nothing can make you feel ashamed or defeated without your permission. As you go through each chapter and study materials, be sure to approach every question as if you are already an entry level practitioner- with boldness and confidence. This too will come to pass at its own perfect time, even if you can’t see that timeline today. Trust yourself and the great destiny of your life.