The Basic Knowledge Assessment Tool for 
Neonatal Intensive Care, Version Five
NICU-BKAT5r  (2016)


    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 35 years, it has become accepted as one standard for measuring basic knowledge in critical care nursing. To date, over 23,000 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. However, at this time our research shows that the BKATs are generally useful only in English-speaking countries.

    The NICU-BKAT5r  is a 74 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-BKAT5r takes approximately 45 minutes to complete. The total possible score is 74 points. Items on the test contain multiple choice and a 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-BKAT5.

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Previous Versions:   The NICU- BKAT1 - NICU-BKAT4

     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, research, and through comments by nurses working in NICUs. The NICU-BKAT1 has been revised three times and is now the NICU-BKAT5 (Version Five) (see below). 

    Reliability was measured using Cronbach’s Coefficient Alpha as the measure of internal consistency for all versions 1 - 4. The reliability of the NICU-BKAT1 was alpha = 0.81, measured on 60 neonatal intensive care nurses from nine different states in the USA. Reliability of the NICU-BKAT2 was alpha = 0.80, computed on a second sample of 68 NICU RNs from 6 different states. Reliability of the NICU-BKAT3 was alpha = 0.76, measured on a sample of 53 NICU RNs, again from 6 different states. Reliability of the NICU-BKAT4 was alpha = 0.73, measured on a sample of 43 NICU RNs, again from 8 different states.  

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

    Average per-cent scores over the past, 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 . Scores on the NICU-BKAT4 ranged from 47 (62.7) to 75 (100%), with a mean of 63.1 (84.1% correct answers). It is noted that as the average scores increased, the SD decreased as more of the nurses were doing better on the test.  


Demographic Characteristics of the Sample

    Sample. All nurses in the USA sample worked in the NICU, with the large majority (81.7%) staff nurses. The remainder were In-service Educators (n=5, 8.3%), clinical specialists (n=2, 3.3%), and one Patient/Family Educator (1.7%).  

    Fifty (83.3%) were critical care/NICU nurses with 1 to 41 years of experience (Mean [M]=16.8 years, standard deviation (SD) 12.7, and ten (16.7%) were new graduates with <1 years experience in critical care/NICU nursing.  

    The largest category of the highest level of nursing education completed was the Associate Degree (n=26, 43.3%), followed by the Bachelors Degree (n=22, 36.7%), and the Masters Degree (n=6, 10.0%), and Diploma (n=6, 10.0%). The type of hospital included the following: Community (n=24, 40.7%), community/teaching (n=33, 55.9%), State/Government (n=1, 1.7%), and Other (n=1, 1.7%). In addition, the large majority were not certified in NICU nursing (n=46, 76.7%), and the remainder held certification (n=14, 23.3%). The type of certification of the 11 who responded included, in the following areas: RN Neonatal Intensive Care Nursing Certification [RNC-NIC] (N=7), RN Certification in Low Risk Neonatal Nursing [RNC-LRN] (N=2), and RN Certification in High Risk Neonatal Intensive Care [RNC-HRNIC] (n=2).  

Validity and Reliability

    Content validity: Panel of Experts. The NICU-BKAT5, the fifth and most recent version of the test, was developed from the NICU-BKAT4:  Changes were made to the NICU-BKAT4 in 21 items to remove the use of the word, except, in all of these questions. In addition, the wording of an additional 13 stems was modified to improve clarity, and 12 distractors and 1 answer were changed. No items were added, nor deleted. Changes that were made, came from clinical experience and the comments of the three-member Panel of Experts. 

    Construct validity again supported for the NICU-BKAT. Construct validity was supported by the technique of known group differences, comparing new graduate nurses (n=10) to those with > 1 years experience. Average scores: The new graduate’s scores on the NICU-BKAT5 ranged from 39% to 72% correct answers, with a mean of 62.3% and a standard deviation of 11.5: The experienced RN’s scores ranged from 63% to 99% correct answers, with a mean of 79.5% and a standard deviation of 8.3  

    A t-test was computed to compare scores. Results showed that the experienced nurses of 1 to 41 years of experience in NICU/critical care nursing) had higher scores than the new graduates: t alpha 1 (58)=5.4, p<.0005, significant, lending support to the construct validity or ability of the NICU-BKAT5 to discriminate between new graduates and experienced nurses working in the NICU environment.

    Reliability of the Fifth Version of the NICU-BKAT was again measured using the Kuder Richardson20 formula and was KR20 = 0.84, measured on 60 NICU RNs from the following eight states: Arizona, California, Florida, Iowa, Kentucky, Ohio, and Virginia. The sample included nine (9) new graduates.

    In response to the item analyses computed during reliability testing, the NICU-BKAT5, the following minor changes were made: Changes in the wording of five answers, one stem, and 13 distractors. One item was deleted no items were added. As a result, the NICU-BKAT5 became the NICU-BKAT5r with the ‘r’ representing revised.

Other Important Findings

    NICU RNs with Certification had higher NICU-BKAT5 scores. Scores of the 47 experienced NICU/ICU RNs, and held certification (n=14) as described above, were compared to those who did not hold certification (n=33), using a t-test. The results were statistically higher in the certified RNs t1 (20.3)=2.2, p<.04, Significant. The M for the certified RNs was 84.5, (SD) = 9.2 points. The non-certified RNs was M=78.3, SD 7.3 points. This is consistent with previous research on the BKATs.

    NICU RNs with more experience had higher NICU-BKAT5 scores. Also consistent with previous research findings using the BKATs, scores of the experienced NICU/ICU RNs, were statistically correlated to scores on the NICU-BKAT5 than those with less experience, r(47)=0.46, p1 <.0005, sign. 

    Higher scores occurred for non-supervised test-taking than supervised.   Unlike previous reports, scores of the 47 experienced NICU/ICU RNs, were compared related to whether or not they were supervised while taking the NICU-BKAT5. The mean score of those who were supervised (n=19) was 76.3% (SD=9.7); those who were not supervised (n=26) was higher at 82.0% (SD=5.7), t1 (27.1)=2.3, p<.03, significant. It is therefore recommended that additional studies be conducted, and supervision vs non-supervision be measured. It is noted that the SD was wider in those RNs who were supervised.

Uses of the NICU-BKAT5r

        The BKAT can be used:

    1.Prior to orientation classes in critical care nursing to identify needed content
              for the classes,
    2.As a pretest and/or a post-test to measure learning in groups of nurses,
    3.As a dependent variable to test different teaching methods for orientation classes, 
    4.To identify content for in-service education programs for currently employed critical  
              care nurses, 
    5.In nursing research, and
    6.For advanced 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.  

NOTE: 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 by every critical care RN to use the BKAT.    No BKAT may be placed on any computer for any reason.

Passing Score for NICU-BKAT5r

    No one is expected to achieve 100%. Rather, it is expected that following orientation, neonatal intensive care nurses will achieve an average score of 80%  correct answers on the NICU-BKAT5r. 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- BKAT5r

    The NICU-BKAT5r 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 $25.00 is requested to cover the costs of photocopying, postage, handling, continued revisions, and validity and reliability testing. Additional information on what BKATs are offered can be obtained at the BKAT Website  

    Permission to use the NICU-BKAT5r is given to individual NICU RNs, who have signed an Agreement Form see It is not to be distributed to other NICU RNs, who must obtain their own permission. This permission to use the NICU-BKAT5 and to photocopy it can be obtained by writing to J. Toth, RN, MSN, PhD, BCCC,  at the following address:

J.Toth, RN, MSN, PhD, BCCC
PO Box 6295
Washington, DC 20015

Panel of Experts for the NICU-BKAT5r

The Panel of Experts for the NICU-BKAT5r included the following critical care nurses:

Kara Johnson, BSN, RN, Washington, DC
Angelina Rangel, MSN, RN, CCRN, LNC, Texas
Jan Thape, MSN, WOCN, RNC-NIC, Virginia

Data Collectors for NICU-BKAT5r

Data collectors for the NICU-BKAT5r included the following:

Elizabeth Burcin, MS, RNC-NIC, Arizona
Rita Crum, BA, RN, Kentucky
Heather Goodall, MSN, RNC-NIC, IBCLC, California
Oveda Hockenheimer, MSN, RN, RNC-NIC, CNL, Florida
Lori Holleman, MSN, RNC-NIC, Virginia
Margaret Kelly, MSNed, RNC, Arizona
Julie Medas, MSN, APRN, CNS, Ohio
Nikki Sliefert, BSN, RN, CNS, Iowa

Author of the NICU-BKAT5r
            Each version of the NICU-BKAT was authored by:


P. O. Box 6295
Washington, DC 20015

Other BKATs Available

            BKAT-9r  for Adult ICU (2015)
            BKAT-9S for Telemetry/Progressive Care (2015)
            PICU-BKAT6r for Pediatric ICU (2014)
                    ED-BKAT3r for Emergency Department (2020)
                    PICU- BKAT6r for Pediatric Emergency Department (2014)
                    MED-SURG BKAT2  (2018).

Selected References

Articles by the Author

    Toth JC. The Participation of Emergency Nurses in the Development of the Basic Knowledge Assessment Tool (BKAT) for the Adult Emergency Department, the ED-BKAT2. Journal of Emergency Nursing. 2013;39(3): 238-243. May.

    Toth JC. Development of the Basic Knowledge Assessment Tool for Medical-Surgical Nursing (MED-SURG BKAT) and Implications for In-Service Educators and Managers. Nursing Forum. 2011;46(2): 110-116. April-June.

    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. October-December.

    Toth JC. Follow-up Survey 10 years later: Use of the Basic Knowledge Assessment Tools (BKATs) for Critical Care Nursing & Effects on Staff Nurses. Critical Care Nurse. 2006;26(4):49-53. 

    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. 

    Runton, N, & Toth JC. Staff Development: Introducing the Basic Knowledge Assessment tool of Pediatric Critical Care Nursing (PEDS-BKAT). Critical Care Nurse. 1998;18(3):67-72. 

    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. [First Article.]  

Articles by Other Authors

    Blackburn, LM, Harkless, S, & Garvey, P. Using Failure-to-Rescue Simulation to Assess the Performance of Advanced Practice Professionals. Clinical Journal of Oncology Nursing. 2014;18(3):301-306.

    Long, DA, Mitchell, ML, Young, J, & Rickland, CM. Assessing Core Outcomes in Graduataes: Psychometric Evaluation of the Pediatric Intensive Care Unit-Nursing Knowledge and Skills Test. Journal of Advanced Nursing. 2013; 70(3), August: 698-708. [Australia}

     Lakanmaa, RL, Suominen, T, Perttila, J, Ritmala-Castren, M, Vahlberg, T, & Leino-Kilpi, H. Graduating Nursing Students’ Basic Competence in Intensive and Critical Care Nursing. Journal of Clinical Nursing. 2013; 23, 645-653. [Finland]

    Lakanmaa, RL, Suominen, T, Perttila, J, Ritmala-Castren, M, Vahlberg, T, & Leino-Kilpi, H.  Basic Competence in Intensive and Critical Care Nursing: Development and Psychometric Testing of a Competence Scale. Journal of Clinical Nursing. 2013; 23, 799-810. [Finland]

    Fulbrook, P, Albarran, JW, Baktoft, B, & Sidebottom, B. A Survey of European Intensive Care Nurses; Knowledge Levels. International Journal of Nursing Studies. 2012; 49, 191-206. [Australia, Denmark, United Kingdom]

    Morris, LL et al. Designing a Comprehensive Model for Critical Care Orientation. Critical Care Nurse. 2007;27(6): 37-60.

    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. [Finland]

    Makarem, S, Dumit, NY, Adra, M, Kassak, K. Teaching Effectiveness and Learning Outcomes of Baccalaureate Nursing Students in a Critical Care Practicum: A Lebanese Experience. Nursing Outlook. 2001;49: 43-49. [Lebanon]

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

  JT 02/20/20                    TO SEE SAMPLE QUESTIONS, Click Here