The Basic Knowledge Assessment Tool (BKAT) for
Emergency Department (ED-BKAT2)Critical Care Nursing
(Version Two, 2012)


Basic knowledge in critical care nursing is a body of knowledge beyond that required for licensure as an RN, that the critical care nurse uses in order to provide safe nursing care to patients.  Since safe practice is regarded as a moral and professional responsibility, basic knowledge is information that is necessary for entry into critical care nursing and represents the foundation for job performance.

A primary aim of in-service education in critical care nursing is to assure that staff nurses demonstrate an understanding of this basic knowledge.  Because of on-going research studies (since 1979), publications, and the use of the BKAT over the past 33 years, it has become accepted as one standard for measuring basic knowledge in critical care nursing.  To date, approximately 17,200 critical care nurse educators and nurse managers in the USA have requested and have received a copy of the BKAT to photocopy for use in their practice.  Critical care nurses in over 27 different foreign countries have also requested and received a copy of one of the BKATs.


The ED-BKAT2 is a 85-item paper and pencil test that measures basic knowledge in critical care nursing in Emergency Departments. The focus is on adult patients, but questions on pediatrics are also included.  These items measure content related to the following areas of ED critical care nursing practice:  cardiovascular, pulmonary, neurology, renal, endocrine, pediatrics, gastrointestinal/parenteral, OB/GYN, trauma, and other.  The category ‘other’ includes such areas as drug abuse, psychiatric situations, rape, and mass casualty.

The BKAT takes approximately 40 minutes to complete and has been administered on a supervised and unsupervised basis with no statistical difference in scores.  The total possible score for the ED-BKAT2 is 85 points.  Items on the test contain multiple choice and fill-in-the-blank questions that measure both the recall of basic information and the application of basic knowledge in practice situations.  Psychosocial aspects of critical care nursing practice are integrated into specific questions in the BKAT.



The ED-BKAT2 is based on version one or the ED-BKAT1; that in turn, was based on its parent test, the adult BKAT.  Content for the ED-BKAT2 was identified through a review of the literature and a nine-member Panel of Experts.  The Experts were from hospital settings across the USA; specifically, from the following states:  Georgia, Iowa, Massachusetts, New Hampshire, New Jersey, Ohio, and Pennsylvania.  All were volunteers and names were obtained from ED RNs who had initiated contacted with the author through the BKAT Webpage www.BKAT-toth.org.  Four held a baccalaureate degree and four a masters degree in nursing; one held a DNP.  Five were Certified Emergency Nurses (CENs).

Content validity.  The Panel of Experts was also used to validate what specific content on the ED-BKAT1 remains basic to safe nursing practice in the Emergency Department.  This evaluation of the ED-BKAT1 included the following:

Whether or not items still apply to the adult ED,
If an item needs rewording,
How basic an item is to adult ED nursing on a scale of 1 to 5 with
                1 being most basic, and
Items that need to be added to the test.

Items were retained if the majority of Panel Members rated them as current practice and as basic knowledge in the Emergency Department.   Items were deleted, if they were outdated.  Other items were revised.  Item analyses on the ED-BKAT1 were also used to evaluate the percentage of ED RNs who correctly answered each item, the item to total correlations for each item, and the distribution of choices made by the 126 sample of ED RNs who took the test.  Revisions also included making the ED-BKAT2 shorter. 

Revisions included the following: 

17 items were deleted, 
2 new items, suggested by the Panel, were added,
the wording of 15 stems were updated/revised,
the wording of the stems of an additional 14 items was made to remove
                the words, ‘all the following EXCEPT’, from the stems,
6 answers were reworded for clarity,
changes were also made in 14 answers and distractors that resulted from
                removing the word, ‘EXCEPT’, from the stem, and
24 distractors were reworded for clarity and to make items either easier
               or more difficult.

Construct validity was supported previously with the ED-BKAT1 using the technique of known group differences.  The two groups, ‘known’ to be clinically different were new graduate nurses with zero to < 1 year experience working in the ED and RNs with 1 to 39 years of experience in ED nursing, also working in the ED at the time the test was taken.  Scores of the new graduates (M= 75.1, SD= 8.4) were compared to the experienced RNs (M=83.2, SD=7.5) using a one-tail independent t-test.  Results showed the two groups to be significantly different, with the new graduates scoring lower on the ED-BKAT:  t(137) = 3.8, p< .0005.  Of note, the ED-BKAT measured this difference.

As the number of new graduates in the data collection for the ED-BKAT2 was small (5%), known group differences were not computed for the ED-BKAT2.


ED BKAT.  The reliability of the ED-BKAT1 was measured on 139 nurses working in an ED or Trauma Center. Reliability was measured using Cronbach’s coefficient alpha and ranged from 0.80 to 0.83.  The mean score was 83% correct answers with a standard deviation (SD) of 7.5 points.

Reliability for the ED-BKAT2 was also measured using Cronbach’s coefficient alpha and was measured on 126 nurses working in an ED or Trama Center and was 0.82. 


The sample of critical care nurses who answered the ED-BKAT2 were from 17 different states across the USA.  These were:    California, Florida, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Nebraska, Nevada, New Jersey, Pennsylvania, Tennessee, Texas, Virginia, and Wyoming.

Units:  The majority of the nurses who answered the ED-BKAT2 worked in a hospital ED (51.0%), followed by Level II Trauma Center (27.5%), Level  III Trauma Center (10.8%), Level I Trauma Center (5.9%), a PEDS-ED (2.9%), and an ‘other’ category that included a Critical Access Unit, and what was noted as a ‘CD’ Unit.  Education:  Close to half held a Bachelor’s Degree (46.1%), with 39.2% Associate Degree, 9.8% Diploma, and 3.9% Master Degree RNs. 

Job:  The great majority were staff nurses (82.2%), followed by managers/supervisors (6.9%), head nurses (5%), in-service educators (3%), and clinical nurse specialists (2%).  Type of hospital:  A little over two-thirds (69%) of the sample worked in community hospitals, and the remaining one-third (31%) in community/teaching hospitals. CEN:  Approximately one-fourth held Certification in Emergency Nursing (24.5%).  Over three-fourths (79%) indicated that this is the first time they had taken a BKAT. 

Scores on the ED-BKAT2

Scores ranged from 42 (49.4%) correct answers to 84 (98.8%) on the 85 item test.  The mean score was 81.6%, SD = 7.3 points.

Uses of the BKAT

The BKAT can be used in the following ways:

prior to orientation classes in critical care nursing to identify neede
                      content for the classes,
as a pretest and/or a posttest to measure learning in groups of nurses,
as a dependent variable to test different teaching methods for
                       orientation classes,
as a means to identify content for in-service education progr
       for currently employed critical care nurses,
in evidence based nursing research, and
for advance placement of nurses with prior experience
                       in critical care nursing.

The BKAT is only one measure of basic knowledge in critical care nursing and is not to be used in screening, hiring, or firing situations.  It is copyrighted  and may not be altered, added to, or used in part.  Permission must be obtained to use the BKAT. No BKAT may be placed on any computer for any reason.  BKATs are not available to travel nurses or nurse agencies.

Passing Score

No one is expected to achieve 100%.  Rather, it is expected that following orientation, critical care nurses will achieve an average score.  For the ED-BKAT2, this is 69 to 70 points (81%-82%)

Whether or not an average score is considered to be a passing grade depends upon which specific questions are missed; for example, being able to recognize the ECG pattern of ventricular fibrillation is critical to know in any unit.  Since the BKAT is being used in a wide variety of clinical settings, which specific questions are essential to know for that setting is decided by the RN administering the BKAT.

Requests for Copies of the ED-BKAT2

The BKAT is being provided at cost to nurses who work in critical care as a service to nursing and to the ministry that nursing represents.  A payment of $15.00 is requested to cover photocopying, postage, handling, and continued validity and reliability testing.  Permission to use the ED-BKAT2 and to photocopy it can be obtained by writing to Dr Jean C Toth, RN, at:

P. O. Box 6295
Washington, DC 20015

Panel of Experts for the ED-BKAT2

The Panel of Experts for the ED-BKAT2 included the following critical care nurses:

Karen Beinhaur, MSN, RN, CEN, New Hampshire
Kristie Gallagher,  BSN, RN, CEN, NREMT-P, Ohio
Andrew Harding, MS, RN, CEN, NEA-BC, FAHA, Massachusetts
Anita Johnson, BSN, RN, Georgia
Lisa Koser, MSN, RN, ACNP-BC, Ohio
RaeAnn Menke, BSN, RN, Iowa
AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, Pennsylvania
Kathleen Patrizzi, MSN, RN, CEN, New Jersey
Cynthia Smith, BA, RN, PCCN, TNCC, Ohio

Data Collectors for ED-BKAT2

Melissa Alvardo, BSN, RN, CEN
Mike Banish, BSN, RN, CEN, Michigan
Dorothy Brownlie, RN, CCRN, Maryland
Karen Clark-Bond, BS, RN, CEN, NREMT-P, Wyoming
Toni Downen, MSN, RN, CEN, Nevada
Steve Draeger, RN, CEN, CFRN, MICN, California
Andrew Harding, MS, RN, CEN, NEA-BC, FAHA, Massachusetts
Barbara Hissong, MSN, RN, CCRN, Florida
Donna Kousaie, BSN, RN, CEN, Maine
Terry Laidlow, DNP, MS, RN, Maryland
Sharon Lee, MSN, RN, APRN, FNP-BC, CEN, CCRN, Nebraska
Betty McGee, BSN, RN, Kentucky
Virginia McGhee, RN, CEN, Virginia
Diane Michal, MS, RN, Texas
Kimberly Montgomery, BSN, RN, CCRN-CMC, Texas
Jan Rhoads, MSN, RN, CEN, Pennsylvania
Cheryl Riwitis, MSN, RN, CEN, FNP-BC, CFRN EMT-B, Indiana
Kathleen Spinelli, BSN, RN, CEN, Massachusetts
Melissa Wafer, MSN, RN, CEN, Louisiana
Georgita Washington, PhD, RN-BC, CCNS, Tennessee
Elizabeth Whetzel, BS, RN, CEN, CPEN, FN-CSA, EMT-B, New Jersey

Author of the BKAT

Each version of the BKAT was authored by:

Jean C Toth, PhD, RN, MSN, CV-CNS, BCCC
Associate Professor of Nursing
The Catholic University of America

Other BKATs Available

    Critical Care BKATs[MUST  be working in critical care to order these]

BKAT-8 for adult ICU (2009)
BKAT-8S for Telemetry/Progressive Care (2010)
PICU-BKAT6r for Pediatric ICU (2014)
NICU4-BKAT for Neonatal ICU (2009)
PEDS-ED BKAT for Pediatric ED (2011)

    Non Critical Care BKAT [MUST  be working in med/surg to order this]

MED-SURG BKAT for Medical/Surgical Care (2011)

Selected References

Toth JC.  Development of the Basic Knowledge Assessment Tool (BKAT) for medical-surgical nursing (MED-SURG BKAT) © and implications for in-service educators and managers.  Nursing Forum.  2011; 46(2):110-116.

Kim YH & Jang KS.  Effect of a simulation-based education on cardo-pulmonary emergency care knowledge, clinical performance ability and problem solving process in new nurses. J Korean Acad Nurs.  2011;41(2):245-255.

Stravroudis TA, Miller MR, & Lehmann CU.  Medication errors in neonates.    Clinics in Perinatology.  2008;35,141-161.

Hoffman RL,  O’Donnell JM, & Kim Y.  The effects of human patient simulators on basic knowledge in critical care nursing with undergraduate senior baccalaureate nursing students. Simulation in Healthcare:  The Journal of The Society for Medical Simulation.  2007:2(2):110-114.

Herdrick B, Lindsay A.   Nurse residency programs.  Journal for Nurses in Staff Development.  2006;March/April:55-62.

Collins ML, Thomas TL.  Creation of a stepdown nurse internship program.  Journal for Nurses in Staff Development.  2005;May/June:115-119.

Ritmala-Castren M, Leino-Kilpi H, Suominen T.  Biological & physiological knowledge & skills of graduating Finnish nursing students to practice in intensive care.  Nurse Educ Today.  2004;24(4):293-300.

Lam, BCC, Lee, J, & Lau, YL.  Hand hygiene practices in a neonatal intensive care unit:  A multimodal intervention and impact on nosocomial infection. Pediatrics.  2004;114(5),565-571.

Messmer PR, Jones SG, Taylor BA.  Enhancing knowledge and self-confidence of novice nurses:  The “Shadow-A-Nurse ICU program.  Nursing Education Perspectives. 2004;25(3):131-136.

Messmer PR, Jones SG, Rosillo C.  Using nursing research projects to meet Magnet recognition program standards. Journal of Nursing Administration. 2002;32(10):538-543.

Wynd, C.  Evidence-based education and the evaluation of a critical care course.  Journal of Continuing Education in Nursing.  2002;33(3):119-125.   

Runton NG, Toth JC.  Introducing the Basic Knowledge Assessment Tool for pediatric critical care nursing (PEDS-BKAT).  Critical Care Nurse.  1998;18(3):67-72.

Toth JC.  Development of the Basic Knowledge Assessment Tool (BKAT) for the NICU:  The NICU-BKAT3, its uses and effect on staff nurses.  Journal of Perinatal Neonatal Nursing.  2007;21(4):  342-348.

Toth JC.  Follow-up Survey 10 years later:  Use of the Basic Knowledge Assessment Tools (BKATs) for critical care nursing and effects on staff nurses.  Critical Care Nurse.  2006:26(4):49-53.

Toth JC.  Comparing basic knowledge in critical care nursing between USA and foreign nurses:  An international study. American Journal of Critical Care.  2003;12(1):41-46.

Toth JC.  Basic Knowledge Assessment Tool for critical care nursing, Version Four (BKAT-4):  Validity, reliability, and replication.  Critical Care Nurse.  1994;14(3):111-117.

Toth JC, Dennis MM.  The Basic Knowledge Assessment Tool (BKAT) for critical care nursing:  Its use and effect on orientation programs.   Critical Care Nurse.  1993;13(2):98-105.

Toth JC.  The Basic Knowledge Assessment Tool (BKAT)—Validity and reliability:  A national study of critical care nursing knowledge. W J Nurs Res.  1986;8(2):181-196.

Toth JC.  Evaluating the use of the Basic Knowledge Assessment Tool (BKAT) in  critical care nursing with baccalaureate nursing students.  Image:  The Journal of Nursing Scholarship.  1984;16(3):67-71.

Toth JC, Ritchey KA.  New from nursing research:  The Basic Knowledge Assessment Tool (BKAT) for critical care nursing.  Heart  Lung.  1984;13(3):271-279.

JT 7/14/12