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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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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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Type of critical care unit Adult intensive care Telemetry/Progressive care Pediatric intensive care unit Adult emergency department Neonatal intensive care unit
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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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 *
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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
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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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
251 18
93.3 6.7
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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
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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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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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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