The Basic Knowledge Assessment Tool
For Neonatal Intensive Care Nursing, Version Four ©  
(NICU-BKAT4) 2009


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 30 years, it has become accepted as one standard for measuring basic knowledge in critical care nursing.  To date, over 9,200 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 24 different foreign countries have also requested and received a copy of one of the BKATs.

The Latest Version of the NICU- BKAT

The NICU-BKAT4 is a 75 item paper and pencil test that measures basic knowledge in neonatal intensive care nursing.  These items measure content related to the following areas of critical care nursing practice:  cardiovascular, pulmonary, gastrointestinal/parenteral, neurology, renal, monitoring lines/catheters, family/spiritual care, and other. The category ‘other’ includes such areas as developmental care, sleep, pain, and blood incompatibilities.

The NICU-BKAT4 takes approximately 45 minutes to complete .  The total possible score is 75 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 NICU nursing practice are integrated into specific questions in the NICU-BKAT4.


Background on the NICU- BKAT1 through NICU-BKAT3

Content for the initial version of the NICU-BKAT called the NICU-BKAT1 was taken from the PEDS-BKAT.  It had 85 items; 47 PEDS-BKAT items were modified for use in the NICU-BKAT1 and 38 new items were added.  These were identified through a review of the literature and through the suggestions from a five member Panel of Experts in neonatal intensive care nursing practice and education.

  Validity for the NICU-BKAT1 through the NICU-BKAT4 was established through the respective Panel of Experts and through comments by nurses working in NICUs.  The NICU-BKAT1 has been revised three times and is now the NICU-BKAT4 (Version Four) (see below).

Reliability was measured using Cronbach’s Coefficient Alpha (a) as the measure of internal consistency for all versions.  The reliability of the NICU-BKAT1 is a = 0.81, measured on 60 neonatal intensive care nurses from nine different states in the USA.  Reliability of the NICU-BKAT2 is a = 0.80, computed on a second sample of 68 NICU RNs from 6 different states.  .  Reliability of the NICU-BKAT3 is a = 0.76, measured on a  sample of 53 NICU RNs, again from 6 different states.

Average scores on the NICU-BKAT1 (85 items) ranged from 34 to 80 points, with a M= 55.6 points (65.4% correct answers) and a standard deviation (SD) of 8.4 points.  The NICU-BKAT2 (80 items) ranged from 34 to 72 with M=58.5 (73.2% correct answers), and a SD = 7.6.  The NICU-BKAT3 (75  items) ranged from 46 to 70 with M=59.3 (79.0% correct answers), and a SD = 6.1

It is noted that as the average scores increased, the SD decreased as more of the nurses were doing better on the test.  Also, as the average scores increased, the reliability decreased from 0.81 to 0.76, still an acceptable Coefficient Alpha.

The NICU-BKAT4 (2009)

Content validity.  The NICU-BKAT4, the fourth and most recent version of the test, was developed from the NICU-BKAT3:  Three items were deleted, and stems and/or distractors or answers were updated or modified in 34 items to improve the clarity of the items and to better reflect current practices in NICUs.  Three items were added.  Changes were made from information gained through a four member Panel of Experts, review of the literature, and item analyses.  

In response to the item analyses following reliability testing (see below), the following minor changes were made:  Changes in the wording of five answers, one stem, and 13 distractors.  No items were deleted or added.

Reliability of the Fourth Version of the NICU-BKAT was again measured using Coefficient Alpha and was a = 0.725, measured on 43 NICU RNs from the following eight states:  California, Florida, Kentucky, Maryland, Michigan, New Jersey, Ohio, and Washington.  The sample included seven new graduates.

[Reliability was also computed on the answers to the NICU-BKAT4 of Australian NICU nurses.  The alpha was a = 0.82, measured on 39 experienced NICU nurses and four new graduates.]

Sample.   All nurses in the USA sample worked in the NICU, with the large majority (72.1%) staff nurses.  The remainder were managers/supervisors (n=3, 7.0%), in-service Educators (n=5, 11.6%), clinical specialists (n=3, 7.1%), and one Neonatal Nurse Practitioner (2.3%). 

Thirty-six (83.7%) were experienced nurses and seven (16.3%) were new graduates with <1 years experience.  Experience in any critical care unit ranged from zero to 34 years (Mean [M] = 13.2, Mdn = 10.0 years). 

The majority held a bachelors degree (n=21, 48,8%, followed by an Associate Degree (n=14, 32.6%), masters degree (n=6, 14.0%), and Diploma (4.7%).   The type of hospital included the following:  Community (n=19, 45.2%), community/teaching (n=15, 35.7%), university (n=5, 11.9%), and three Children’s specialty hospitals (7.1%).  This was the first time taking any BKAT for all but one of the subjects.

Construct validity.   First, construct validity was supported by the technique of known group differences, comparing new graduate nurses (n=7) to those with > 1 years experience.  A t-test was computed on scores.  Results showed that the experienced nurses (>1 to 34 years experience in critical care nursing) had higher scores:  t a1 (41)=2.8, p<.005, lending support to the construct validity or ability of the NICU-BKAT4 to discriminate between new graduates and experienced nurses.

Secondly, a t-test was computed between the NICU nurses who were certified and those who were not, with higher scores occurring in the certified:  t a1 (41)=2.9, p<.005, lending support to the construct validity or ability of the NICU-BKAT4 to discriminate between NICU nurses who are certified (n=16) and those who are not (n=27).   Certifications included the following:  NCC-NICU, NNP, NRP, NN and RNC.

Average scores.   Scores on the NICU-BKAT4 ranged from 47 (62.7) to 75 (100%), with a mean of 63.1 (84.1%).  The goal of revising the NICU-BKAT to improve average scores was met, or that the test difficulty was more appropriate than the previous three versions.

Uses of the BKAT

The BKAT can be used prior to orientation classes in critical care nursing to identify needed content for the classes, and as a pretest and/or a posttest to measure learning in groups of nurses.  It can also be used as a dependent variable to test different teaching methods for orientation classes, and as a means to identify content for in-service education programs for currently employed critical care nurses.  In addition, it has been successfully used in nursing research and for advance placement of nurses with prior experience in critical care nursing, so that they do not have to attend classes that present content that they already know.  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.

Passing Score

No one is expected to achieve 100%.  Rather, it is expected that following orientation, neonatal intensive care nurses will achieve an average score of 83% to 84% correct answers on the NICU-BKAT4.  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 respiratory distress is critical to know in any unit.  As BKATs are being used in a wide variety of clinical settings, which questions are essential to know for that setting is decided by the nurse administering the BKAT.

Requests for Copies of the NICU- BKAT4

The NICU-BKAT4 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 the costs of photocopying, postage, handling, and continued validity and reliability testing.  Additional information on what BKATs are currently offered can be obtained at the BKAT Website

Permission to obtain a copy and use the NICU-BKAT4 and to photocopy it can be obtained by writing to Jean C Toth, RN, MSN, PhD, BCCC, Associate Professor of Nursing, The Catholic University of America, at the following address:

Jean C Toth, RN, MSN, PhD, BCCC
PO Box 6295
Washington, DC 20015

  To order Click Here.

Panel of Experts for the NICU-BKAT4

The Panel of Experts for the NICU-BKAT4 includes the following critical care nurses:

Emily Bearse, RN, MSN, Maryland
Kathleen Buckley RN, PhD, Maryland
Amy Johnson, RN, PhD, Delaware
Kristen Woods, RN, MSN, FNP, Maryland

Data Collectors for NICU-BKAT4

Data collectors for the NICU-BKAT4 included the following:

Patricia Beam, RN-BC, MSN, Ohio
Anneliese Crawford, RNC, Kentucky
Martine DeLisle-Porter, RNC, MN, Washington
Kimberly Hayes-Hart, RN, MSN, NNP-BC, Michigan
Cindy Jacobs, MSN, RNC-NIC, RN-BC, Indiana
Ann Johnson, RN, Maryland
Kirsi Lindfors, RN, MNS, Finland
Diane McClure, RN, MSN, CCRN, CPNP, New Jersey
Sue Moore, RNC, CPN, ENPC, Florida
Amy Seekely, RN, BSN, Ohio
Kaye Spence, AM, RN, RM, MN, FCN, Australia
Beverly Walti, RN, MSN, CPNP, CNS, California
Karen Williamson, RNC-NIC, BSN, Maryland

Author of the NICU-BKAT4

Each version of the NICU-BKAT was authored by:

Jean C Toth, RN, CV-CNS, BC, MSN, PhD
The Catholic University of America
Washington, DC 20064

Other Critical Care BKATs Available:

BKAT-8 for Adult ICU (2009)
BKAT-8Sr for Telemetry/Progressive Care (2010)
       ED-BKAT2 for Adult Emergency Department (ED) (2012)
PICU-BKAT6r for Pediatric ICU (2006)
PEDS-ED BKAT for the Pediatric ED (2011)

Non-Critical Care:

MED-SURG BKAT for medical-surgical nursing (2010)

Selected References

Morris, LL et al.  Designing a comprehensive model for critical care orientation. Critical Care Nurse.  2007;27(6): 37-60.

  McConnell EA, Fletcher J, Nissen JH.  A comparison of Australian and American registered nurses’ use of life-sustaining medical devices in critical care and high-dependency units. Heart Lung. 1993;22(5):421-427.

Recker D, O’Brien C.  Reliability and validity of critical care orientation tests.  J Cont Educ Nurs.  1995;26(1):21-27.

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.

Aari, R-L, Riitta-Liisa A, Ritmala-Castren, M, Leino-Kilpi, H, & Suominen, T.  Biological and physiological knowledge and skills of graduating Finnish nursing students to practice in intensive care.  Nurse Education Today.  2004;24:293-300.

Santiano N, Daffurn K, Lee A.  The Basic Knowledge Assessment Tool:  Is it useful?  Aust Crit Care.  1994;7(4):18-23.

Smith-Blair N, Neighbors M.  Use of the Critical Thinking Disposition Inventory in critical care orientation. J Cont Educ Nurs.  2000;31(6):251-256.

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

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) October-December.

Toth JC.  Comparing basic knowledge in  critical care nursing between nurses from the United States and nurses from other countries.  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):111-117.

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.             

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