AN INDEPENDENT VOICE FOR NURSING

Development of the Basic Knowledge Assessment Tool for Medical-Surgical Nursing (MED-SURG BKAT) and Implications for In-Service Educators and Managers
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Jean Toth, PhD, RN, MSN, CV-CNS, BCCC Jean Toth, PhD, RN, MSN, CV-CNS, BCCC, is Associate Professor of Medical-Surgical Nursing, The Catholic University of America, School of Nursing, Washington, DC. Keywords In-service education and management, medical-surgical nursing, patient safety Correspondence Jean Toth, PhD, RN, MSN, CV-CNS, BCCC, The Catholic University of America, School of Nursing, Washington, DC 20064 E-mail: bkat7.toth@yahoo.com
BACKGROUND OF THE PROBLEM. Medical-surgical nursing is now the largest specialty in acute care, and needs an objective measure of basic knowledge necessary to provide safe care to patients. The Joint Commission on Accreditation of Healthcare Organizations noted that healthcare organizations have in the past relied on education and experience to support competence, but an increasing number are seeking objective measures of a nurses knowledge that is required for safe practice. The American Nurses Association adds that safe practice is both a professional and a moral responsibility. PROBLEM. A review of the literature failed to locate a standardized test of basic knowledge in medical-surgical nursing. In-service educators and managers need such a test to facilitate orientation programs, and as a way to safely decrease the length of orientation for new employees with previous experience in medical-surgical nursing. METHODS. The purpose of the study was to develop a valid and reliable test to measure basic knowledge in medical-surgical nursing. FINDINGS. The Basic Knowledge Assessment Tool for Medical-Surgical nursing was developed with support for its validity and reliability.

Introduction Basic knowledge in medical-surgical nursing is a body of knowledge that the registered nurse (RN) uses in order to provide safe nursing care to patients (Toth, 2010). This knowledge includes such concepts as ethical decision making, the nursing process, health promotion, stress and adaptation, pain management, uids and electrolyte balance, acute and chronic illness, perioperative nursing, and the assessment and function of the respiratory, cardiovascular, renal, immune, skin, sensory, endocrine, gastrointestinal, hematologic, neurologic, and musculoskeletal systems
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(Basic Nursing, 2010; Brunner, Smeltzer, Bare, Hinkle, & Cheever, 2011; Ignatavicius & Workman, 2010; Osborn, Wraa, & Watson, 2010; Potter & Perry, 1999; Springhouse, 2007; Swearingen, 2003). The Academy of Medical-Surgical Nursing (AMSN) states that originally Medical-surgical nursing [was] the foundation of all nursing practice (About AMSN, 2010, p. 1). However, medical-surgical nursing has evolved as an adult health specialty today (Hanks, 2010a), and medical-surgical nurses are knowledgeable in all aspects of adult health . . . and consider patient safety to be the top priority (About AMSN, 2010, p. 1). This standard of patient safety is discussed next.

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In-Service Education In-service education, or that which is provided to nurses as part of their job benets and/or requirements, has the primary aim of assuring that staff nurses demonstrate an understanding of this basic knowledge. These in-service education programs are integral to evaluating/building the knowledge nurses have related to the unit in which they are working (Bastable, 1997), and include but are not limited to orientation (Dellasega, Gabbay, Durdock, & MartinezKing, 2009; Morris et al., 2007), and residency/ internship and continuing education programs (Bratt, 2009; Wynd, 2002). Benedict and Bradley (2010) further discuss professional responsibilities by describing the core values of the ANAs publication, the revised Nursing Professional Development: Scope and Standards of Practice. One of the core values, mentoring and peer review, points out the need to dene knowledge in specialty areas, such as medical-surgical nursing, and the ability to measure that knowledge for continuing nursing education programs (Benedict & Bradley, 2010). Indeed, the revised Scope and Standards provide a framework for improving nursing practice through continuing nursing education for medical-surgical nurses. It is within this professional and moral context that a brief review follows, which describes the background of why BKATs were developed.

Theoretical Framework: Benecence and Patient Safety As safe practice is regarded as a professional and moral responsibility (American Nurses Association [ANA], 2001; Krner et al., 2006; Torjuul & Sorlie, 2006), basic knowledge is information that is necessary for entry into the specialty area of medicalsurgical nursing. Professionally, the ANA specically addresses in Provision 3 of The Code of Ethics of the ANA (2001) that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (p. 5). In addition, in its Guide to staff education, the Joint Commission on Accreditation of Healthcare Organizations (JCHCO) states that . . . a hospital cannot provide safe reliable, and appropriate health care if its staff members are not competent (Joint Commission Resources, Inc., 2008, p. 1). Furthermore, the JCHCO points out that competence involves critical thinking and the ability to transfer knowledge and skills to new tasks and situations (Joint Commission Resources, Inc., 2008, p. 2). This knowledge is dened by them as information the nurse needs to be a safe practitioner (Joint Commission Resources, Inc., 2008). Although healthcare organizations have in the past relied on education and experience to support competence, an increasing number of them are seeking objective measures of a nurses knowledge that is required for them to be safe practitioners (JCHCO, 2007). The Basic Knowledge Assessment Tool (BKAT) series, including the Medical-Surgical Basic Knowledge Assessment Tool (MED-SURG BKAT), offers such objective measures. From a moral perspective, Krner et al. (2006), Beauchamp and Childress (2009), and others write about the ethical principle of benecence, to do good, and of non-malecence, to do no harm (King, 2009). Polit and Beck (2008) discuss benecence as one of the most fundamental ethical principles in human research, and Potter and Perry (1999) refer to ethics as standards of conduct and the ideals of right and wrong behavior. These authors continue by linking ethics to competence or the ability to perform specic tasks related to patient care (Potter & Perry, 1999). Minimizing harm is thus seen as integral to knowledge that is basic, to the provision of safe nursing care to patients seen in medical-surgical settings (Polit & Beck, 2008; Potter & Perry, 1999; Torjuul & Sorlie, 2006), and further undergirds the rationale for the development of the MED-SURG BKAT.

The BKATs Because of ongoing research studies (since 1979), publications, and the use of ve different critical care BKATs over the past 31 years, the BKAT series of tests has become accepted as one standard for measuring basic knowledge of critical care nursing (Toth, 2010). Table 1 lists these BKATs: Three apply to adult critical care and two to pediatric critical care. The BKAT for adult critical care has received the most requests: Information on development and uses for in-service educators have been published for the BKAT Versions 1 through 7 (Morris et al., 2007; Ritmala-Castren, Leino-Kilpi, & Suominen, 2004; Toth, 1984, 1986, 1994, 2003, 2006; Toth & Dennis, 1993; Toth & Ritchey, 1984). The latest versions of the BKATs are currently in use throughout the United States and in multiple international nursing settings (Ritmala-Castren et al., 2004; Santiano, Daffurn, & Lee, 1994; Toth, 2003).
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Table 1. Basic Knowledge Assessment Tools (BKATs)

Name BKAT-8 (version eight) BKAT-8S (version eight, short [S] form) PEDS-BKAT5 (version ve)a ED-BKAT NICU-BKAT4 (version four)b
a

Type of critical care unit Adult intensive care Telemetry/Progressive care Pediatric intensive care unit Adult emergency department Neonatal intensive care unit

Year version released 2009 2010 2006 2006 2009

N items on tool 90 80 96 100 75

Alpha reliability 0.88 0.77 0.85 0.800.83 0.730.82

Runton & Toth (1998). bToth (2007).

A review of the literature, however, failed to locate a standardized test of basic knowledge in medicalsurgical nursing, the largest area of nursing practice (Osborn et al., 2010; About AMSN, 2010). It was in response to this nding and inquiries from nurses across the United States, asking if a BKAT for medicalsurgical nursing exists, that this research was begun. This is the rst BKAT that has been developed outside of the critical care setting. Purpose The purpose of the study was to develop a valid and reliable test to measure basic knowledge in medicalsurgical nursing. The MED-SURG BKAT The MED-SURG BKAT is an 88-item paper and pencil test that measures basic knowledge in medicalsurgical nursing. These items measure content related to the following areas of nursing practice: cardiovascular (19 items), endocrine (12 items), renal (10 items), neurology (7 items), gastrointestinal/ parenteral (7 items), pulmonary (7 items), skin/ wounds (5 items), and an other category (21 items). The other category includes pain control (4 items); safety/falls (4 items); infection control (3 items); communication, emotional/spiritual care, and drug calculation (2 items each); and one item each for advanced directives, blood transfusion, hypothermia, and obesity (Bennett-Kanarek, 2010; Hanks, 2010b; Shapiro, Donaldson, & Scott, 2010; Taylor, 2005). See Figure 1 for examples of items on the test. The MED-SURG BKAT takes approximately 40 min to complete. The total possible score is 88 points (100%). Items on the test contain multiple choice and ll-in-the-blank questions that measure both the
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Figure 1. Sample Questions on the MedicalSurgical Basic Knowledge Assessment Tool

12. In a symptomatic sinus bradycardia, which of the following could be used to increase the heart rate: 1) 2) 3) 4) 21. Inderal digoxin atropine * verapamil

The most important step in preventing central venous catheter related sepsis is: 1) 2) 3) 4) use of a semi-permeable membrane dressing weekly catheter changes using antibiotic ointment thorough handwashing *

52.

When feeding a patient using continuous tube feedings, the most important intervention in preventing aspiration is to: 1) 2) 3) 4) keep the head of the bed elevated * do frequent chest PT check the position of the feeding tube each shift aspirate stomach contents q4h

_____ * Correct answer.

recall of basic information and the application of basic knowledge in practice situations. Psychosocial aspects of nursing practice are integrated into specic questions in the MED-SURG BKAT. Possible scores range from 0 to 88 points, with a high score indicating a high degree of basic knowledge in medical-surgical nursing, and a low score representing a low degree of this basic knowledge. Item Analyses Based on the item analyses of the 284 subjects who answered the MED-SURG BKAT, minor changes were made to improve clarity of 27 (30.7%) of the questions. This included minor changes in stems (n = 4), in stems and distractors (n = 2), in stems and the order of the responses (n = 1), in distractors (n = 17), and in distractors and the order of responses (n = 2). In

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(56.2%) were RNs/new graduates with <1 year of experience in nursing. There were no doctorally prepared nurses in this study. Table 2 also shows that the staff nurse position represented almost three quarters of the nurses studied. The other category included RNs/new graduates with <1 year of experience in an extern/intern (n = 23) or residency program (n = 16), and one nurse who held a consultant position. Almost 90% of the sample were working in the community setting. Eighteen RNs stated that they held certication in medical surgical nursing: None of these were the RNs/new graduates with <1 year of experience. Validity and Reliability Validity Content for the initial version of the MED-SURG BKAT was identied through clinical experience, a review of the literature, interviews with staff nurses and head nurses working in medical-surgical nursing, a 10-member Panel of Experts working in management, education, and/or practice positions in medicalsurgical nursing, and from items from the BKAT-7S for Telemetry/Progressive Care (http://www.BKATtoth.org, Toth, 2010). The BKAT-7S contained 85 questions: Fifty-three were used (62.4%) for the MED-SURG BKAT. Of these, 22 (41.5%) were modied to better reect medical-surgical nursing. Modications included changes in stems, answers, and/or distractors. Content validity was supported through the Panel of Experts. The standard used by the Panel was the denition of basic knowledge, or information that the nurse working in medical-surgical nursing needs to know in order to provide safe nursing care to patients who are hospitalized there. The Panel addressed the following objectives: (a) whether or not items on the BKAT-7S for Telemetry/Progessive Care Unit apply to medical-surgical nursing; (b) if an item needed rewording and suggestions for the rewording; (c) to determine how basic any chosen or suggested item to medical-surgical nursing is on a scale of 15, with 1 being the most basic; and (d) to identify items that need to be added to the test. In addition, 121 potential new items were suggested by the Panel. Many suggested items were similar among the panelists; 28 (23.1%) were used. An additional seven items were written by the author and added to the test.
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addition, grammar was corrected in one of the distractors. The remainder of items (n = 61, 69.3%) were left unchanged. Validity and reliability are discussed following a short description of the sample used in reliability testing. Description of the Sample Data were collected from nurses in 14 different states. These included medical-surgical nurses from Arizona, Delaware, the District of Columbia, Florida, Illinois, Indiana, Michigan, Minnesota, Nevada, Ohio, Pennsylvania, Tennessee, Virginia, and Texas. Although not planned, there were equal numbers of RNs with one or more years experience in medicalsurgical nursing, and new RNs/Graduate Nurses with <1 year experience. The mean (M) years for the experienced RNs ranged from 0 (new to medical-surgical nursing) to 40 years, with an M = 9.5 and standard deviation (SD) of 8.9 years. The experience of the new RNs/Graduate Nurses with <1 year experience ranged from 0 (n = 107, 89.2%) to 0.6 years, with an M = 0.03 years and SD = 0.12. Table 2 illustrates that the majority of nurses held the highest degree of associate degree. Of these, 86

Table 2. Demographic Characteristics of the Sample N = 284

Variable Educational preparationa Associate degree Diploma Bachelors degree Masters degree Position in nursingb Staff nurse Head nurse Manager/supervisor In-service educator Other Type of hospitalc Community Community/teaching University Military/veterans Certication in medical-surgical nursingd No Yes Frequency 153 15 103 7 205 9 9 11 40 138 98 25 1 % 55.0 5.4 37.1 2.5 74.8 3.3 3.3 4.0 14.6 52.3 37.1 10.2 0.4

251 18

93.3 6.7

Missing values: an = 6, bn = 10, cn = 19, dn = 15.

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Construct validity was supported through suggestions from the Panel of Experts. During reliability testing, additional construct validation was conducted. This included two strategies. First, the known group difference technique was used to compare basic knowledge of new graduate nurses to experienced nurses (Polit & Beck, 2008). Experienced critical care nurses have consistently been found to have a higher level of basic knowledge in critical care nursing than that required for the RN (Toth, 1984, 2010). However, it has not been reported if there is a difference in basic knowledge between new graduates and experienced medical-surgical nurses. Therefore, MED-SURG BKAT scores of new graduates (M = 74.5% correct answers, SD = 6.9) were compared with scores (M = 76.0% correct answers, SD = 6.9) of the medical-surgical nurses with greater than 1 year of experience. An independent t-test was found to be not statistically signicant (t[282] = 1.5, NS), or knowledge for safe practice, the standard for the RN (National Council of State Boards of Nursing, 2010), in medical-surgical nursing was not different. Second, the MED-SURG BKAT was used as a pretest and a posttest for 18 new graduate nurses in two different internship/residency programs from Delaware (n = 15) and Tennessee (n = 3). As cognitive learning theory would predict (Bastable, 1997; Billings & Halstead, 2009), posttest scores were signicantly higher, t(17) = 2.18, p < .025 one tail. The length of the programs ranged from 10 to 16 weeks. These ndings are similar to a much earlier study by Toth (1984), using the BKAT at the beginning and end of baccalaureate nursing students in a senior elective in critical care nursing. Learning theory was also used in that study. Reliability
5.

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methods for orientation and residency/internship programs, and as a means to identify content for in-service education programs for currently employed medical-surgical nurses. Challenging Full Orientation Is Cost-Effective The MED-SURG BKAT is particularly useful in identifying knowledge basic to safe practice of nurses with prior experience in medical-surgical nursing, so that they do not have to repeat content that they already know. Also, of special interest is the Score Sheet that accompanies the MED-SURG BKAT (see Figure 2). This Sheet identies content areas for study that individual nurses with previous medical-surgical experience may miss more than others, or be one means to validate that the nurse should proceed to the next phase of the orientation process following study in that particular content area(s). Being able to

Figure 2. Score SheetMedical-Surgical Basic Knowledge Assessment Tool

Content Area 1. Cardiovascular a. Assessment & care b. EKG interpretation c. Emergency situations d. Drugs e. CVA Questions #

01,11,14,16,17,19 04,05 06,07,18,20 03,08,12,13,15 09,10

6 2 4 5 2 (19) 7 3 1 1 (12) 8 2 (10) 6 1 (7) 5 1 1 (7) 7 (7) 5 (5) 1 1 2 2 2 1 3 1 4 4 (21)

2.

Endocrine a. Diabetes Mellitus assessment & care 23,24,25,26,27,31,33 b. Drugs 29,30,34 c. Stress 28 d. Diabetes insipitus 32 Renal a. Assessment & care b. Drugs Neurology a. Assessment & care b. Drugs Gastrointestinal/parenteral a. Assessment & care b. Nutrition c. GI bleeding Pulmonary: Assessment & care Skin/wounds: Assessment & care Other a. b. c. d. e. f. g. h. i. j. Advanced directives Blood transfusion Communication Drug calculation Emotional/spiritual care Hypothermia Infection control Obesity Pain control Safety/falls 35,36,37,39,40,42,43,44 38,41 45,46,47,48,50,51 49 53,54,55,56,58__ 52 57 59,60,61,62,63,64,65 67,68,69,70,71 80 82 86,88 02,78 66,87 73 21,22,72 79 74,75,76,77 81,83,84,85

3.

4.

Cronbachs coefcient alpha (a), used to measure reliability of the MED-SURG BKAT, ranged from 0.80 to 0.72, computed toward the beginning of the study (n = 20) and at the end of the study (N = 284). Implications for In-Service Educators and Managers The BKAT can be used prior to orientation classes in medical-surgical 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
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6. 7. 8.

TOTAL

88

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ington, DC; Andrea Heimer, RN, MSN, CCRN, Illinois; Ramona Hercules, RN-BC, BSN, Arizona; Kathy Hoffmann, RN, BC, BSN, Arizona; Tejuana Holmes, RN, BSN, MS, Tennessee; Penny Huddleston, RN, MSN, CCRN, Irving, Texas; Kristin Labbe, RN, MSN, CNS/AH, Fort Worth, Texas; Tammie Luman, RN, BSN, Florida; Cora Luz, RN, BSN, CPAN, Dallas, Texas; Deborah Mabrey, RN, MSN, Dallas, Texas; Janice Marl, RN, BSN, Michigan; Michelle Marty, RN, BSN, Fort Worth, Texas; Kim Montgomery, RN, CCRN, Fort Worth, Texas; Janette Moss, RN, MSN, NE-BC, Nevada; Cheryl Mufey, RNC, BSN, Delaware; Virginia Payne, RN, ADN, Dallas, Texas; Elizabeth Scruggs, CMSRN, BS, Virginia; Mary Jean Vickers, RN, MS, APRN, BC, Minnesota; Jane Wrede, RN, MSN, Illinois; and Denise Zabriskie, RN, RN-BC, WCC, Nevada. Visit the Nursing Forum blog at http://www. respond2articles.com/NF/ to create, comment on, or participate in a discussion.
References About AMSN. (2010). What is medical-surgical nursing? American Academy of Medical-Surgical Nurses. Retrieved from http://www.amsn.org/aboutamsn/ whatismedicalsurgicalnursing American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. Bastable, S. B. (1997). Nurse as educator: Principles of teaching and learning. Boston: Jones and Bartlett. Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press. Benedict, M. B., & Bradley, D. (2010). A peek at the revised Nursing Professional Development: Scope and standards of practice. Journal of Continuing Education in Nursing, 41(5), 195196. Bennett-Kanarek, R. (2010). Viewpoint, palliative care isnt just for the dying. American Journal of Nursing, 110(7), 11. Billings, D. M., & Halstead, J. A. (2009). Teaching in nursing: A guide for faculty (3rd ed.). St. Louis, MO: Saunders/ Elsevier. Bratt, M. M. (2009). Retaining the next generation of nurses: The Wisconsin nurse residency program provides a continuum of support. Journal of Continuing Education in Nursing, 40(9), 416425. Brunner, L. S., Smeltzer, S. C. D., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2011). Brunner and Suddarths textbook of medical-surgical nursing (12th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Dellasega, D., Gabbay, R., Durdock, K., & Martinez-King, N. (2009). An exploratory study of the orientation needs of experienced nurses. Journal of Continuing Education in Nursing, 40(7), 311316. Hanks, R. G. (2010a). The medical-surgical nurse perspective of advocate role. Nursing Forum, 45(2), 97107.
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challenge full orientation is cost-effective for the institution, and offer a means to in-service educators and managers of an objective measure of knowledge recommended by both the ANA and the JCHCO. Passing score. No one is expected to achieve 100%. Rather, it is expected that following orientation, medical-surgical nurses will achieve an average score. Whether or not an average score is considered to be a passing grade depends upon which specic questions are missed; for example, being able to prevent falls is recognized as critical to know in any nursing unit. Because the BKAT is being used in a wide variety of clinical settings, which specic questions are essential to know for that setting are decided by the nurse administering the BKAT. The BKAT is to be administered only to RNs. Requests for copies of the MED-SURG BKAT. The MED-SURG BKAT is being provided at cost to nurses who work in medical-surgical units, as a service to nursing and to the ministry that nursing represents. The BKATs are copyrighted. To order a copy, contact Jean C. Toth, RN, PhD at PO Box 6295, Washington, DC 20015, or send an e-mail to bkat7.toth@yahoo.com. Additional information related to what BKATs are available and what research is currently being conducted can be found on the Ofcial BKAT Webpage at http://www.BKAT-toth.org. Acknowledgments. Panel of Experts for the MEDSURG BKAT. The MED-SURG BKAT is dedicated to a Panel Member who died in 2008: Nelda Logan, RN, C, BSN, Fort Worth, Texas. Other Panel members include: Dora Bradley, RN-BC, PhD, Professional Development, Dallas, Texas; Mark Handy, RN-BC, MSN, Washington, DC; Candice Hanrahan, RN, MSN, CSC, CCRN, Bethesda, Maryland; Cora Luz, RN, BSN, CPAN, Dallas, Texas; Deborah Mabrey, RN, Dallas, Texas; Michelle Marty, RN, BSN, Fort Worth, Texas; Tracey McCall, RN, BSN, Fort Worth, Texas; Virginia Payne, RN, Dallas, Texas; Ruth Rekha, RN, MSN, FNP-C, PCCN, CMSRN, Garland, Texas. Data Collectors for the MED-SURG BKAT include: Mallory Atilano, RN, MSNEd, CCRN, CNRN, Arizona; Kendra Bishop, RN, MSN, Ohio; Julie Bowen, RN, Illinois; Yvonne Brown, RN, MA, Texas; Marianne Bundy, RN, BS, CEN, Florida; Jeanine DeLucca, RN, BC, MSN, Pennsylvania; Pamela Dunn, RN-BC, MSN, Virginia; Shellie Fedis, RN, BSN, CAPA, CPAN, Arizona; Norma Hall, RN, BC, MSN, Indiana; Martinious Handy, RN-BC, MSN, Wash-

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Hanks, R. G. (2010b). Development and testing of an instrument to measure protective nursing advocacy. Nursing Ethics, 17(2), 255267. Ignatavicius, D. D., & Workman, M. L. (Eds.) (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed.). St. Louis, MO: Saunders/Elsevier. Joint Commission on Accreditation of Healthcare Organizations. (2007). Assessing hospital staff competence. Oakbrook Terrace, IL: Joint Commission Resources. Joint Commission Resources, Inc. (2008). The joint commission guide to staff education (2nd ed.). Oak Brook, IL: Joint Commission Resources. King, C. A. (2009). Primum non nocere: Above all [or rst] do no harm. AORN Journal, 90(4), 489492. Krner, U., Bondol, A., Bhler, E., MacFie, J., Meguid, M. M., Messing, B., . . . Allison, S. P. (2006). Ethical and legal aspects of enteral nutrition. Clinical Nutrition, 25(2), 196 202. Morris, L. L., Pfeifer, P. B., Catalano, R., Fortney, R., Hilton, E. L., McLaughlin, J., . . . Goldstein, L. (2007). Designing a comprehensive model for critical care orientation. Critical Care Nurse, 27(6), 3760. National Council of State Boards of Nursing. (2010, September 17). Re: The testing of entry-level nursing competence of candidates for licensure as registered nurses [Web message]. Retrieved from http://www.ncsbn.org/index Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medicalsurgical nursing: Preparation for practice. Boston: Pearson. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Potter, P. A. (Ed.). (2010). Basic nursing (7th ed.). St. Louis, MO: Mosby Elsevier. Potter, P. A., & Perry, A. G. (1999). Basic nursing: A critical thinking approach (4th ed.). St. Louis, MO: Mosby. Ritmala-Castren, M., Leino-Kilpi, H., & Suominen, T. (2004). Biological and physiological knowledge and skills of graduating Finnish nursing students to practice in intensive care. Nurse Education Today, 24(4), 293300. Runton, N. G., & Toth, J. C. (1998). Introducing the Basic Knowledge Assessment Tool for pediatric critical care nursing (PEDS-BKAT). Critical Care Nurse, 18(3), 6772. Santiano, N., Daffurn, K., & Lee, A. (1994). The basic knowledge assessment tool: Is it useful? Australian Critical Care, 7(4), 1823. Shapiro, S. E., Donaldson, N. E., & Scott, M. B. (2010). Rapid response teams: Seen through the eyes of the nurse. American Journal of Nursing, 110(6), 2834.

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Springhouse. (2007). Medical-surgical nursing made incredibly easy (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Swearingen, P. L. (Ed.) (2003). Manual of medical-surgical nursing care: Nursing interventions & collaborative management. St. Louis, MO: Mosby/Elsevier. Taylor, E. J. (2005). What have we learned from spiritual care research? Journal of Christian Nursing, 22(1), 22 28. Torjuul, K., & Sorlie, V. (2006). Nursing is different than medicine: Ethical difculties in the process of care in surgical units. The Authors. Journal compilation [BMC Medical Ethics]. Oxford: Blackwell Publishing. Toth, J. C. (1984). Evaluating the use of the Basic Knowledge Assessment Tool (BKAT) in critical care nursing with baccalaureate nursing students. Image: Journal of Nursing Scholarship, 16(3), 6771. Toth, J. C. (1986). The Basic Knowledge Assessment Tool (BKAT)Validity and reliability: A national study of critical care nursing knowledge. Western Journal of Nursing Research, 8(2), 181196. Toth, J. C. (1994). Basic Knowledge Assessment Tool for critical care nursing, Version Four (BKAT-4): Validity, reliability, and replication. Critical Care Nurse, 14(3), 111 117. Toth, J. C. (2003). Comparing basic knowledge in critical care nursing between USA and foreign nurses: An international study. American Journal of Critical Care, 12(1), 4146. Toth, J. C. (2006). 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, 26(4), 4953. Toth, J. C. (2007). 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, 21(4), 342348. Toth, J. C. (2010). The MED-SURG BKAT. Retrieved from http://www.BKAT-toth.org Toth, J. C., & Dennis, M. M. (1993). The Basic Knowledge Assessment Tool (BKAT) for critical care nursing: Its use and effect on orientation programs. Critical Care Nurse, 13(2), 98105. Toth, J. C., & Ritchey, K. A. (1984). New from nursing research: The Basic Knowledge Assessment Tool (BKAT) for critical care nursing. Heart and Lung, 13(3), 271 279. Wynd, C. (2002). Evidence-based education and the evaluation of a critical care course. Journal of Continuing Education in Nursing, 33(3), 119125.

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