It just never ends. As healthcare travelers we must repeatedly prove our ability to deliver expert patient care at every stop along the road. Our accumulated clinical experience, solid references and glowing performance evaluations are necessary keys to opening the door to new assignments, but each encounter with a client facility brings with it a new burden to demonstrate our skills.


In most cases we will begin the first day of orientation when we are handed a stack of tests and a #2  pencil - or the computer equivalent. New travelers may be surprised and dismayed to learn they will face a fresh barrage of competency tests with each assignment. Here is the breakdown of what to expect:

Tests may be paper and pencil, computer-based, or even verbal. Every nurse traveler should expect a medication test including basic pharmacology and dose calculations. Test questions on general nursing skills will typically be given. For those assigned to telemetry or critical care areas, a cardiac arrhythmia test is customary. Critical care nurses may be also tested on commonly used emergency medications (code drugs). You may see a critical thinking test in which various scenarios are portrayed and about which you will be asked one or more questions. Common to these tests is that you will be expected to recognize events and situations that are immediate threats to patient safety and identify the appropriate interventions. Competency tests can range from easy and undemanding to very comprehensive and difficult. Usually, but not always, the proctor will allow you to use a drug reference book and a calculator. At most hospitals these tests must all be passed before you are permitted to engage in patient care. You must have solid clinical experience to thrive as a traveler. If you are a proficient practitioner you'll pass these tests with only modest review and preparation. No matter your experience level, and even if you're an expert test-taker, most of us approach testing with at least some trepidation. And for a traveler, some apprehension is warranted. Failing a test during orientation has the potential to abruptly end your assignment - before you even begin. You could be discharged immediately from your contract, finding yourself thousands of miles from home without a job. This harsh policy is not universal, but neither is it rare. You'll find there are many varieties of competency tests used in hospitals. All competency tests  are intended to be objective – they should have specific, unequivocally correct answers. Unfortunately this is not always the case. Although they are all intended to verify the skills you claim to possess, and to determine your suitability for the position, all tests are not created equal. For this article I'll divide them all into three categories:

  • "Academic Quality" tests are validated using standard criteria to prove that their methodology is well-founded and corresponds accurately to the real world. These will look familiar to you, closely akin to exams encountered in school. 
  • Another broad category is "In-House" exams. These tests are of unpredictable quality. They are internally generated by staff nurse educators, often hodge-podge collections of copied (frequently plagiarized) test questions from commercial exams, or a combination of both. In-house exams are perhaps the most common type found in U.S. hospitals.
  • And finally, in a category all its own, falls the singular "Performance Based Development System" more often called by its acronym PBDS.

The most widespread academic-quality test used - particularly in critical care practice areas - is the Basic Knowledge Assessment Tool, or BKAT. The BKAT test is  both a valid and reliable objective test.   As of this writing, Version 8, revised in 2008 is the current ICU version. It is a traditional paper and pencil test, and comes in a number of specialty-specific versions. Here's a sample question from the MED-SURG test:

  • A 55 year old, post-operative patient with a history of an irregular heart rate is found slumped on the bathroom floor. The patient is assisted back to bed and is noted to have weakness on one side. Signs and symptoms of stroke include all of the following EXCEPT:

          1) unexplained headache

          2) sudden weakness on one side of the body

          3) abrupt shortness of breath  <Correct Answer>

          4) trouble speaking or understanding

Remarkably,  a copy of the actual test in your specialty will be provided by BKAT author Jean C. Toth at cost, to nurses working in that particular specialty. The test is provided, in Dr. Toth's words, "as a service to nursing and to the ministry that nursing represents."  A small fee is requested to cover "photocopying, postage, handing, and continued validity and reliability testing."

The appropriate version for your specialty can be obtained by writing to co-author Jean C. Toth, RN, MSN, PhD; P O Box 6295, Washington DC, 20015. Since the BKAT is never provided to agencies, you have to take this step for yourself. Currently, BKAT comes in the following flavors: Adult ICU, NICU, ED, PEDS-ED, PEDS, Telemetry/Progressive Critical Care Nursing, and MED-SURG.  

If you travel to smaller hospitals you are bound to encounter many "in-house" tests. These range in quality from excellent to abysmal. Some have been photocopied so many times that they are difficult to even read. This is particularly problematical with ECG rhythm tests that may be indecipherable. Don't be distracted by poorly written test questions found on these in-house generated tests. You, the experienced clinician, should recognize the correct answer. Don't be shy about asking the proctor for clarification of troubling questions during the test.

In recent years the PBDS (Performance Based Development System) test has gained a foothold in U.S. hospitals. It is a startling departure from standard testing. In this test you view brief videotaped vignettes that simulate clinical situations. You are expected to write down all the steps you would take to manage these clinical situations including what you believe to be the primary problem or medical diagnosis (yes, a medical diagnosis that only physicians are licensed to make!). Your answers are in essay form, not multiple choice. Depending on the individual hospital, answers are written on a paper answer sheet or typed into a computer template.  

A number of hospitals are using PBDS during traveler orientation as a pass/fail screening device. According to PMSI (the company that developed and owns the test) President Elliot Saulten, this is an off label misue of their test. This misuse is often compounded by untrained hospital employees ranking the results rather than PMSI trained rankers, with subjective and inconsistent results.

"The purpose of PBDS is to individualize orientation and thereby reduce the costs associated with providing a standardized orientation program for all new hires," Saulten said. He confirms that the test was not intended to be used to make hiring decisions.

He acknowledged that once hospitals purchase his testing products, PMSI has little control over how they are used. Hospitals exercise wide latitude in how they rank these tests and how they use the findings. Saulten warrants the validity of the PBDS when graded as intended - by specially trained evaluators working directly for PMSI.

There are many travelers who have reported having "failed" PBDS during orientation and having their contracts immediately cancelled. This is no true reflection on how qualified the traveler might be in real life. There are some travelers who have "passed" multiple times, only to "fail" at the next assignment. A traveler report from Texas in early 2010 reports that of 55 travelers going through orientation, "only 7 of us passed". She also reported that she had taken PBDS 5 times and passed each time, but after seeing this, never again!

No doubt this incident is not the norm, however it behooves every traveler considering an assignment to determine if PBDS will be given in a pass/fail manner at the facility by asking direct questions of their recruiter (an incomplete list of hospitals requiring PBDS for travelers is maintained here), and consider the reward to risk ratio.

How to pass these tests is suggested by Amat victoria curam or "Victory loves preparation".  

  • First and foremost, you owe it to yourself to determine ahead of time the types of tests to expect before you hit the road to your next assignment.  Ask your recruiter to find out what tests are administered and if it is common at this particular hospital for travelers to be summarily terminated if they don't pass. If the agency is unsure, consider a better known facility.
  • The unconventional format of the PBDS makes preparation rather thorny. While PBDS does not easily lend itself to studying specific topics, it is crucial to learn more about how to take this unusual test. There are several good online resources including a well researched study guide that can be found on this site here.  
  • Request the appropriate version of the BKAT. Do this well ahead of time (now is a good time!) because response time by snail-mail is uncertain. Remember that providing the test is a gift from the author.

Take advantage of these resources:

  • The University of North Carolina at Chapel Hill School of Nursing offers a number of practice quizzes covering PO and IV medication calculations, IV Flow Rate Calculations and metric conversions - complete with solutions to check your math.
  • If you will be working telemetry, or expected to float to telemetry, review common six-second rhythms in lead II (the most common lead displayed on a cardiac monitor). Here is a good online simulator to get you started with your review.

General test taking tips can be found all over the Internet, but here are my three all-time favorites:  

  • Just answer the question. For multiple choice, read the question but cover the answers.  Try to answer without the distraction of the answers being visible to you. The correct or best answer will be close to, or precisely, the answer you chose yourself.  
  • Don't over-think the question. If you know the answer, mark it. Don't fall into the trap of thinking, "It can't be that simple." Many correct answers are just that. Simple.
  • Don't change your answers - usually.  Go with your first choice unless you have an unequivocal reason to reject your first choice.  For instance, a subsequent question has spurred your memory about a specific term you had forgotten.  

Healthcare travel is not for the inexperienced. Don't consider this career path until you are comfortable with most of the skills appropriate to your specialty. Two years experience is a minimum these days.  More is better.  Remember that travelers are held to a higher standard. Healthcare travelers are expected to be the cream of the crop, requiring no remediation of any professional skills. From day one, we are expected to hit the floor running and to be able to perform professionally without close supervision.

Test anxiety is nearly universal. However, as your career as a traveler progresses, you will become so accustomed to taking these competency tests that much of your anxiety - and your vulnerability to failing them - will simply fade away.