The Effect of Advanced Practice Nurse-Modulated Education on Rehabilitation Nursing Staff Knowledge



Kristen L. Mauk, Professor of Nursing and Kreft Endowed Chair, 116 LeBien Hall, Valparaiso University Valparaiso, IN 46383. E-mail:


Rehabilitation is a specialty area with defined competencies and discrete nursing knowledge. Nurses need to be educated in the basic competencies of rehabilitation to provide safe, quality care to patients with chronic illnesses and disabilities. A critical appraisal of the literature showed that education increased knowledge in a specialty area and had positive benefits for nurses, organizations, and patients. The purpose of this paper is to describe an evidence-based educational intervention. Self-study modules on 15 rehabilitation competencies were developed for 16 nurses working on a new inpatient unit. Outcomes were evaluated using pre and post tests via the online Association of Rehabilitation Nurses (ARN) Competency Assessment Tool (CAT). Data were analyzed using the SPSS14.0 statistical package. Paired t-tests demonstrated a significant difference between pre and post test scores on 14 of the 15 competencies measured. Findings suggested that education of nursing staff resulted in increased knowledge about rehabilitation nursing competencies.

Rehabilitation is a specialty area with defined competencies and discrete nursing knowledge. Unless nurses have been educated in the basic competencies of rehabilitation, they are not prepared to provide safe, quality rehabilitative care to patients with chronic illnesses and disabilities. Although rehabilitation may be generally included in basic nursing curricula, few programs include dedicated content or clinical experiences that address nursing competencies in rehabilitation (Booth, Hillier, Waters & Davidson, 2004; Mauk, 2013; Smeltzer, Dolen, Robinson-Smith & Zimmerman, 2005). Good rehabilitation nursing is not something that can be done well without education and a solid knowledge of the rehabilitation process (Lin & Armour, 2004; Pryor, 2002; Remsburg & Carson, 2006).

Significance of the Project

Rehabilitation nursing is a nationally recognized specialty with a core body of knowledge, its own curriculum and research base, specialty organization, and certification (Association of Rehabilitation Nurses, 2007; Association of Rehabilitation Nurses, 2000, 1996). Just as one would not expect a generalist nurse to be competent providing care in an intensive care unit without proper preparation, so it is with rehabilitation care provision. Rehabilitation requires special knowledge, skill sets, and expertise to achieve positive patient outcomes. Rehabilitation nurses use the roles of caregiver, teacher, case manager, counselor, and advocate (Association of Rehabilitation Nurses, 2000). Advanced practice nurses (APNs) have demonstrated success in educating other nurses to promote a positive change and increase the quality of patient care provided in a variety of specialty areas (Bourbonniere & Evans, 2002; Carroll, Rankin & Copper, 2007; Holtrop, Baumann, Arnold & Torres, 2008; Lewandowki & Adamie, 2009; Ong, Miller, Appleby, Allegretto & Gawlinksi, 2009), although little data exist that are specific to the rehabilitation setting.

Staff education has been shown in the literature to have a positive effect on nurses in several areas including job satisfaction, retention, perceived competency, and increased quality of patient care. Having nursing staff certified in rehabilitation would greatly enhance patient care and credibility of a unit (Cherry, Ashcraft, & Owne, 2007; Nelson et al., 2007; Smolenski, 2007). Carey (2001) found that certification increased confidence in a nurse's abilities, resulted in earlier intervention to prevent problems, and provided more nurse/physician collaboration. Booth et al. (2004) stated the global problem well when they said, “far from being categorized as ‘enthusiastic amateurs” nurses aspire to be ‘rehabilitators par excellence’, but there is little evidence in the literature that the necessary educational preparation is available or undertaken to achieve this, despite a number of studies supporting the overall view that specific educational preparation is required” (p. 466).

The purpose of this article is to describe an evidence-based educational intervention provided and modulated by a rehabilitation APN to 16 nurses without prior rehabilitation nursing experience who were working on a newly opened inpatient unit. Self-study modules on 15 rehabilitation competencies were developed for this evidence-based practice project. The compelling clinical question was: What is the effect of education provided by a rehabilitation APN on inpatient rehabilitation nursing staff knowledge? Outcomes were evaluated using pre- and posttests via the online Association of Rehabilitation Nurses (ARN) Competency Assessment Tool (CAT [ARN-CAT]).

Theoretical Framework

The theoretical framework chosen for this EBP project was Rogers' Diffusion of Innovations (DOI) (Rogers, 2003). The model fits well with this EBP project because it provides a framework for which the adoption and use of innovations can affect social change.

Rogers defines innovation as an idea, practice, or object that is perceived as new by a person, unit, or organization. Diffusion is the process through which an innovation is communicated and involves how it is disseminated through a social system or organization (Haider & Kreps, 2004; Rogers, 2004). Diffusion in Rogers' framework is a type of social change that occurs as a result of events related to the invention or adoption, or rejection, of the new idea. DOI has four interacting factors: (1) the innovation or new idea, (2) communication, (3) social systems, and (4) time (Rogers, 2004).

The innovation for this project was the educational intervention. Prior to the proposal of this new idea, there was no set of competencies with which to measure staff knowledge or to use for accreditation purposes. The nursing staff participating in the project had little to no prior experience in rehabilitation. The innovation, then, that was conceptually embraced by the nursing staff, nurse manager and nursing administration, was for an APN rehabilitation expert to provide education to the entire nursing staff on the inpatient rehabilitation unit in the 15 basic competency areas as identified by the ARN.

Review of Literature and Best Evidence

The search engines used to find relevant evidence included: ProQuest, CINAHL, PubMed, Cochrane Library, Joanna Briggs Institute (via JBI COnNECT), and Medline. Keywords in various combinations were sought out in each search engine. These keywords (and all associated words) included rehabilitation, nursing, education, teaching, staff development, staff education, certification, teaching intervention, stroke, advanced practice nurse, clinical nurse specialist. Inclusion criteria were articles in English, dates 1998 or later, and research or evidence-based. Sources included research articles from journals, dissertations, and EBP articles. Evidence that was excluded included those in foreign languages other than English, sources older than 1998, poor quality of evidence, evidence that was not relevant to the EBP project, and sources that did not directly relate to improving knowledge of nursing staff. Consistent with EBP process, the expert opinion of this author was integrated into formation of the EBP recommendations. A couple of expert opinions that appeared in EBP articles were included in the appraisal of literature, as well as two dissertations.

In CINAHL, a total of 39 possible articles related to the keywords yielded only one relevant study, but it was research of a higher level and quality. A PubMed search gave few articles related to rehabilitation and staff education, and only one source specific to teaching of rehabilitation nursing staff. Medline via EBSCO yielded 1308 sources on nursing certification, which dropped to 12 sources when rehabilitation was added as a keyword. Of these, most were not specific to education of the rehabilitation nursing staff, or involved settings such as home care instead of inpatient rehabilitation. ProQuest yielded an initial 52 potential sources based on the keywords, but only one that truly addressed the clinical question. In total, 19 relevant sources were included for this integrative review.

Levels of evidence for this project were categorized using the rating system for the hierarchy of evidence as proposed by Melnyk and Fineout-Overholt (2005). These levels appear in the note to Table 1 which provides a summary of the authors, date of publication, level of evidence rating, and key findings related to the proposed EBP project. The levels of evidence among the selected 19 relevant sources ranged from Level II to Level VII via articles or dissertations as follows: two Level IIs, one Level III, three Level IVs, one Level V, and ten Level VIs, and two Level VIIs. There was no research on the EBP topic of the highest Level I, (i.e., systematic reviews of randomized controlled trials or meta-analyses) and most of the evidence was of the lower strength of evidence.

Table 1. Levels of Evidence from the Appraisal of Literature
Author(s)Level of evidenceKey evidence related to the EBP project
  1. Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice; Level II: Evidence obtained from at least one well-designed RCT; Level III: Evidence obtained from well-designed controlled trials without randomization; Level IV: Evidence from well-designed case–control and cohort studies; Level V: Evidence from systematic reviews of descriptive and qualitative studies; Level VI: Evidence from a single descriptive or qualitative study; Level VII: Evidence from the opinion of authorities and/or reports of expert committees (Melnyk & Fineout-Overholt, 2005, p. 10)

Booth et al. (2004)Level IVEducation for nurses regarding stroke positioning was broken into short 30–90 minute sessions for 7 hours of training; the changes in technique after the education did not significantly increase nurse's time demand, but did result in more measurably therapeutic care for patients
Bulla (2003)Level VIDissertation findings showed that certification status had little bearing on medication administration errors and knowledge about such errors among a group of Navy nurses
Byrne, Valentine and Cater (2004)Level VIProfessional commitment was the primary reason for seeking certification among perioperative nurses
Coleman et al. (2009)Level IVCertified nurses scored significantly higher than noncertified nurses on knowledge of pain management
Gaberson, Schroeter, Killen and Valentine (2003)Level VIThe value of certification was established among perioperative nurses; three factors found to influence certification were personal value, recognition by others, and professional practice
Greenberger et al. (2006)Level VIEducational level was the strongest predictor of knowledge and attitudes about pain among certified and noncertified nurses
Jakubik et al. (2004)Level VIPediatric certification group showed increase knowledge, skill, and leadership, promotions, and better retention rate over noncertified nurses
Jones et al. (1998)Level IINurses in the experimental group who received education and practice on positioning of stroke patients scored higher than those in the control group on a questionnaire about positioning, both immediately after teaching and 3 months later
Kendall-Gallagher and Blegen (2009)Level IIISpecialty certification and competence of RNs were associated with increased patient safety; certified RNs had increased knowledge over noncertified RNs
Leclerc et al. (2004)Level VIThe major reason rehab nurses stated for certification was knowledge gain and professional recognition; a major barrier was finding adequate study time; organizational support for opportunities to work to their full scope of nursing practice was important; rehabilitation nursing certification was valued by nurses
McLaughlin et al. (2008)Level VIRehabilitation nurses lacked knowledge of proxemics; an educational intervention with pre- and posttest was used; there was a significant correlation between higher education and higher posttest score improvement
Nelson et al. (2007)Level IIA 1% increase in certified rehabilitation nurses on a unit resulted in a 6% decrease in length of stay; more years of rehabilitation nursing experience did not significantly affect length of stay; education and training of non-RN staff played an important role in positive functional outcomes
Nieberh and Biel (2007)Level VIICertification was supported and valued among nurses and nurse managers; major incentives for certification were reimbursement and CEUs
Piazza et al. (2006)Level IVCertified nurses perceived a greater level of empowerment and greater access to information than noncertified nurses
Sharoff (2006)Level VIInformal learning strategies helped to achieve competency; good support systems were vital to achieving competency; nurses need to be aware of the need for additional skills and knowledge
Smith et al. (2009)Level VIIColorado Stroke Advisory Board state-wide stroke initiative showed that a stroke database can increase hospital-level and state-wide quality assurance improvement efforts; mentoring and educational programs were reported by participants to be some key aspects of sharing best practice
Smith, Craig, Weir and McAlpine (2007)Level VIHCPs prefer face-to-face accredited education, structured and well-managed clinical education in stroke; HCPs valued multidisciplinary team education; nurses in stroke education were most interested in teaching patients and caregivers
Valentine et al. (2004)Level VICertification status among preoperative nurses was predicted by professional commitment, professional credibility, accountability, attaining standards, and marketability
Zulkowski et al. (2007)Level VWound care certification and education significantly affected nursing knowledge; knowledge scores were significantly higher in the certified wound care group than among those noncertified in wound care

Several articles examined the value of nursing certification in various specialty areas (see Table 1). In a survey of rehabilitation nurses, Leclerc, Holdway, Kettyle, Ball and Keither (2004) found that the major reason Canadian nurses certified in the specialty area was for knowledge gain and professional recognition. This evidence supports that certification is valued among nurses. Piazza, Donahue, Dykes, Griffin and Fitzpatrick (2006) studied 265 nurses and found that certified nurses perceived greater access to information (< .010) and had a greater perception of empowerment than noncertified nurses. Incidental findings from Nelson et al. (2007) showed that a 1% increase in certified rehabilitation nurses on a unit was associated with about a 6% decrease in length of stay.

Educational level has been associated with increased knowledge as well. Among Israeli nurses (Greenberger, Reches & Riba, 2006) in a cross-sectional, descriptive, comparative design, educational level was the strongest predictor of knowledge and attitudes among nursing students and certifying nurses with regard to pain management in patients. On a rehabilitation unit, McLaughlin, Olson and White (2008) tested an educational intervention related to proxemics knowledge among rehabilitation nurses.

Certification was also associated with competence. Kendall-Gallagher and Blegen (2009) studied the competence and certification of RNs and safety of patients in the intensive care unit. This secondary analysis from a retrospective, cross-sectional study of a sample of randomized hospitals (yielding 47 units) showed that “unit proportion of certified staff registered nurses was inversely related to the rate of falls” (p. 106) and that “specialty certification and competence of RNs are related to patients' safety” (p. 106). Coleman et al. (2009) compared certified and noncertified nurses (n = 93), and surveyed 270 oncology patients that they cared for. Results showed that “certified nurses scored significantly higher (p = .02) than noncertified nurses on knowledge of pain management” (p. 170).

In rehabilitation education, Booth et al. (2004) compared two stroke rehabilitation units using a quasi-experimental, nonequivalent control group design with structured observations. Seven hours of formal education related to positioning of stroke patients was broken into 30–90 minutes sessions. Staff was educated on correct positioning and a.m. care of stroke patients. The researchers found the education was effective, and “an altered approach to nurses' practice was demonstrated…with a minimal amount of educational input” (p. 471). In a similar study of positioning of stroke patients, Jones, Carr, Newham and Wilson-Barnett (1998) provided two 2-hour lectures with a workbook and practical skills sessions to 59 staff members (mostly nurses) on six wards, including making 1,000 sets of observations and observing 17,854 aspects of posture among the stroke patients. After three data collection points, nurses in the experimental group scored significantly higher on a questionnaire related to stroke patient positioning than those in the control group, both immediately after teaching and 3 months later.

The available relevant literature supports the benefit of education, increased knowledge, and certification in the specialty area as valuable to nurses, nurse managers, and for improving the quality of patient care. Certification is viewed as one major way to ensure increased competency. Certified nurses tend to have increased competency and skills and provide safer patient care. They tend to score higher on tests of knowledge and skills in their specialty area. Other values of certification included perceived increased empowerment, personal value, professional development, increased competency and skills, and recognition by others. Therefore, the best practice model recommendation is one that aims to increase staff knowledge through an educational intervention, with the ultimate goal of having nurses on the rehabilitation unit become certified in rehabilitation nursing.



The purpose of this EBP project was to increase the knowledge of rehabilitation nursing staff with regard to basic rehabilitation competencies, so the design was an educational intervention. The author developed 15 educational modules based on the set of competencies (see Table 2) used in the ARN-CAT (Association of Rehabilitation Nurses, 2005).

Table 2. The 15 Basic Rehabilitation Nursing Competencies Used in the Intervention
CompetencyOrder assignedNumber of items on ARN-CAT
Autonomic dysreflexia#610
Bladder function#510
Bowel function#410
Musculoskeletal/body mechanics/ transfer techniques#1210
Neuropathophysiology (CVA, SCI, TBI) and functional assessment#1510
Patient and family education#1310
Safe patient handling#710
Skin and wound care#1115

Teaching strategies included one face-to-face educational orientation session at the beginning of the project to introduce staff to the learning modules and the ARN-CAT, as well as how to effectively use them. Fifteen self-guided study modules (each covering a key competency area) were provided. Each module minimally included learning objectives, PowerPoint slide handouts, tables/figures with key information, and at least one article or practice guideline relating to best practice. Pre- and posttests using the online ARN-CAT were used to evaluate outcomes for each competency. Access via phone and e-mail to the author as an educator and expert consultant was provided. Face-to-face evaluation sessions with the author and the nurse manager were ongoing.

Sample and Setting

Participants in the educational project were staff registered nurses working on an 11-bed inpatient rehabilitation unit within a medical center building that was part of a moderately sized acute care hospital system located in a small Midwestern town. A purposeful convenience sample of N = 13 staff nurses participated as volunteers. However, not all of the nurses completed each educational module, so the number (n) of respondents varied with each pre- and posttest.


Nursing staff on the inpatient rehabilitation unit of the participating facility took a pretest using the ARN-CAT, engaged in a self-study using the information in the module, and then took the same questions as a posttest. The teaching and measurement strategies used were negotiated between the author and the rehab nurse manager as ones that would best meet both the needs of the staff, time constraints, and the unit milieu, and still be likely to achieve the desired educational outcomes.


Expected outcomes of the educational intervention were: (1) nurses will demonstrate increased knowledge levels in the basic competency areas for rehabilitation nursing as evidenced by improved scores from the pretest to the posttest, and (2) nurses will verbalize/report a perception of increased knowledge and confidence related to rehabilitation nursing concepts and care provision.

Instrument and Reliability and Validity

The instrument used to measure knowledge was the ARN-CAT. The ARN-CAT does not guarantee competency, but was designed as a useful tool for employers. This set of competency tests was developed, reviewed, and tested by the ARN using expert rehabilitation nurses, so content validity may be assumed to be strong. There are no published reliability or validity statistics for the ARN-CAT, although content validity was established in the process of the development of the tool. A Cronbach's Alpha was run by this author on the 15 pretests taken by the participants in this project with a result of .883 (N = 15), suggesting that the ARN-CAT competency pretests used were indeed reliable for this project.


Institutional Review Board approval was obtained prior to the beginning of the project. Informed consent was obtained from all participants. Participants had potential benefits and risk explained to them verbally and in writing. Anonymity and confidentiality of participant responses were assured.

Prior to the educational intervention, participants attended one joint session of orientation and explanation about the project, including how to use the online ARN-CAT and the self-study educational modules that were provided on the unit. Basic demographic information was obtained from participants and kept confidential for use with data analysis of outcomes.

Each week for a period of about 22 weeks nursing staff members were asked to take an online pretest on one of the assigned topics from the basic competencies using the ARN-CAT that was accessed through the ARN website. The ARN-CAT tests were brief (ranging from 10–15 questions per competency area) and consisted entirely of multiple choice items. The ARN-CAT has 16 competencies total, but the module on pediatrics was excluded from this project since the educational intervention was provided to a unit where all patients are over the age of 18 years. The online tests give the participant immediate feedback with results, correct answers, and rationales with a reference citation for each correct answer. The pretest was used to assist nurses to see their areas of strength and weakness and to help them focus their learning using the educational modules provided by the author.

Participants could choose to take the pretests one at a time each week or consecutively concurrently. However, staff nurses were instructed that the posttest should not be completed until they had reviewed the corresponding educational module. Modules were made available weekly or biweekly over the educational intervention period, but nurses engaged in the self-study process at their convenience as the materials were available.

After taking the online ARN-CAT pretest, the nurses read and studied the materials provided by the author. The author, acting as an APN in the role of educator, numbered the 15 competencies in a logical order and developed the learning modules over several months.

There was a separate, professionally bound spiral book for each of the 15 modules, clearly labeled and available to staff. Each module consisted of the following in order: (1) a cover sheet with the competency number, title, and name of this author who compiled the module, (2) a one-page instruction sheet about accessing the online ARN-CAT pre- and posttests as well as reminders about the process of data collection for the project and contact information for the DNP student, (3) three to four learning objectives, (4) PowerPoint slides with pictures and notes view with additional information, (5) additional helpful tables/figures to promote retention of key facts, and/or an evidence-based practice guideline or screening tool, and (6) an article demonstrating best practice. Additional materials (such as brochures or magazines) were added to enhance learning about the topic. It was anticipated that each module would take 30–60 minutes to complete, although no time limits were set. After reviewing the content of the module, the nurses took the ARN-CAT online posttest, which was exactly the same as the pretest, in the hopes of capturing the impact of the educational intervention.

Management of Data

Measurement of the impact of the educational intervention on knowledge of the rehabilitation nursing staff was based on analysis and comparisons of the pre- and posttests for each module using the SPSS statistical package. Descriptive statistics and frequencies were used to describe the nurses' demographic characteristics. Paired t-tests provided comparisons of pre- and posttests on the ARN-CAT. Bivariate correlations of certain demographic characteristics and pretests provided additional information.


Demographic data were collected on 13 volunteer nurses who participated in the project. Characteristics of the sample population are presented in Tables 3 and 4. Although 13 nurses completed the demographic form and signed a consent form, one nurse did not complete any educational modules at all, accounting for the maximum n of 12 for the various modules. The one individual who completed a consent and demographic form but did not complete any modules worked very minimal hours per month in a prn position.

Table 3. Sample characteristics
TraitRange Mean SD
  1. a

    Rehabilitation knowledge was rated on a 1–5 scale with 1 being Novice and 5 being Expert.

  2. b

    Job satisfaction was rated on a 1–5 scale as follows: 1=very satisfied, 2=somewhat satisfied, 3=neutral, 4=somewhat dissatisfied, 5=very dissatisfied

Age in years (n = 13)28–6345.076911.57196
Years experience (n = 13)3–4117.192310.91928
Months on rehab unit (n = 12)3–118.41672.35327
*Rehab knowledge (n = 13) 2–32.7308.43853
**Job satisfaction (n = 13)1–52.46151.39137
Table 4. Sample characteristics
TraitFrequency(n) result
Gender100% (n = 13) female
Ethnicity100% (n = 13) white
Employment status53.8% (n = 7) full time
 23.1%(n = 3) part time
 23.1% (n = 3) prn
Work elsewhere38.5% (n = 5) yes
 61.5% (n = 8) no
Highest degree7.7% (n = 1) LPN
 53.8% (n = 7) associate degree
 7.7% (= 1) diploma
 23.1% (n = 3) BSN
 7.7% (n = 1) MSN
Certification7.7% (n = 1) yes
 92.3% (n = 12) no
Rehab knowledge 0.0% (n = 0) chose 1/5 (novice)
 23.1% (n = 3) chose 2/5
 7.7% (n = 1) chose 2.5/5
 69.2% (n = 9) chose 3/5
 0.0% (n = 0) chose 4/5
 0.0% (n = 0) chose 5/5 (expert)

Sample Characteristics

All participants were white females (= 13) between the ages of 28 and 63 years, with a mean age of 45.1 (SD = 11.57)(see Table 2). The years of nursing experience within the group varied from 3 to 41 years with an average of 17.2 years (SD = 10.9). As the unit had been open for less than a year, most respondents (53.9%) had worked there for 9 or 10 months, with all but one of the remaining respondents (n = 4 or 33.3%) having been on the rehabilitation unit for less than 9 months. All of the respondents had worked elsewhere prior to their current position in rehabilitation. Seven (53.8%) were prepared at the associate degree level, one was a diploma graduate (7.7%) and four (30.8%) had a BSN degree. Only one (7.7%) was certified in a specialty area, but none were certified in rehabilitation.

Participants rated their rehabilitation knowledge on a continuum. These ratings equated to a mean of 2.73 (SD = .44) on a scale of 1 to 5, with 1 being novice and 5 being expert. All participants rated their rehabilitation knowledge between 2 and 3 on the scale of 1–5 (see Table 3). None rated themselves at levels 4 or 5 (at the second highest and highest levels of proficient and expert).

Changes in Outcomes: Statistical Testing and Significance

Paired-samples t-tests were calculated to compare the mean pretest scores to the mean posttest scores on each of 15 rehabilitation competencies because the test scores were interval level data. The clinical question was answered by the results of the paired-samples t-tests. Educating the rehabilitation nursing staff showed a significant effect in 14 out of 15 rehabilitation competencies. Test scores improved significantly between pre- and post-tests due to the educational intervention. The results for each pair of pre- and posttests appear in Table 5 as paired samples statistics. Table 6 gives the significance of the paired samples tests.

Table 5. Paired Samples Statistics for Pre- and Posttests
PairTestMean (N) SD Std. Error Mean
1 Rehabilitationpre7.7273 (11)1.67874.50616
post9.8182 (11).40452.12197
2 Gerontologypre8.7778 (9).97183.32394
post10.0000 (9).00000.00000
3 Dysphagiapre8.5000 (10)1.35401.42817
post9.9000 (10).31623.10000
4 Bowelpre7.2000 (10)1.47573.46667
post10.000 (10).00000.00000
5 Bladderpre6.7273 (11)1.61808.48787
post9.9091 (11).30151.09091
6 Dysreflexiapre6.7273 (11)2.83164.85377
post10.000 (11).00000.00000
7 Patient handlingpre8.6667 (12)1.23091.35533
post9.8333 (12).38925.11237
8 Disabilitypre9.5714 (7).53452.20203
post9.8571 (7).37796.14286
9 Communicationpre7.6364 (11) 1.50151 .45272
post9.8182 (11).40452.12197
10 Sexualitypre9.1818 (11).98165.29598
post10.0000 (11).00000.00000
11 Skin/woundpre11.1000 (10)2.183270.690411
post14.8000 (10).63246.20000
12 Musculoskeletaltransferspre7.125 (8)1.8077.6391
post10.000 (8).0000.00000
13 Educationpre8.1429 (7)1.06904.40406
post10.0000 (7).00000.00000
14 Painpre9.8000 (10)2.201010.696020
post11.9000 (10).31623.10000
15 Neuropathopre7.7778 (9)1.78730.59577
post10.0000 (9).00000.00000
Table 6. Paired Samples Test Showing Significance between Pre- and Posttest Scores
PairTests t dfSig. (2-tailed)
  1. See Table 2 for the full names of each competency and their associated numbers. Significant items (< .05) appear in bold.

1 Rehabilitationpre/−3.82310 .003
2 Gerontologypre/−3.7738 .005
3 Dysphagiapre/−4.1189 .003
4 Bowelpre/−6.0009 .000
5 Bladderpre/−6.34810 .000
6 Dysreflexia pre/−3.83310 .003
7 Patient handlingpre/−3.38611 .006
8 Disabilitypre/−1.5496.172
9 Communicationpre/−4.51910 .001
10 Sexualitypre/−2.76410 .020
11 Skin/woundpre/−5.1709 .001
12 Musculoskeletal/transferspre/−4.4987 .003
13 Educationpre/−4.5966 .004
14 Painpre/−2.9099 .017
15 Neuropathopre/−3.7308 .006

A significant increase from pretest to posttest was found in all but one of the competencies. The most highly significant results occurred in the pre- and post tests for the bowel (t(−6.000) = .000) and bladder (t(−6.348) = .000) competencies. For competency #8, disability, no significant difference from pretest to posttest was found (t(−1.549) = .172, < .05). The pretest scores for this competency were highest and this competency also had fewer participants (= 7).

Staff nurses on this unit were the weakest in the following areas: autonomic dysreflexia, bowel and bladder function, and musculoskeletal/body mechanics/transfer techniques. This is not surprising, as these represent topics of more unique knowledge in rehabilitation. The staff seemed to have stronger core knowledge in the areas of sexuality and disability as measured by the pretests, which may indicate more general knowledge areas than the areas of greatest weakness.

Bivariate correlations were run between appropriate demographic variables and pretests. Some significant correlations were found, but given the small sample size and the number of demographic variables correlated with 15 pretests, the correlations must be interpreted with caution. Specifically, a Pearson correlation coefficient was calculated for the relationship between age of the respondent and sexuality pretest score. A positive relationship was found (r(11) = .612, < .05), indicating that the greater the age of the participant, the higher the pretest score on the sexuality competency. A positive relationship was also found between the highest degree held in nursing and the scores on the pretest competencies of dysreflexia (r(10) = .725, < .05) and musculoskeletal/body mechanics/transfer techniques (r(7) = .801, < .05). This suggests that nurses who have pursued a higher level of education in nursing performed better on pretests in these topic areas.

Surprisingly, how the participants ranked their rehabilitation knowledge had a moderately strong negative correlation with their scores on the pretests on autonomic dysreflexia (r(11) = −.618, < .05), disability (r(9) = −.689, < .05), and musculoskeletal/body mechanics/transfer techniques (r(8) = −.811, p < .05). These results suggest that the staff nurses may have rated their level of rehabilitation nursing knowledge higher than what the competency pretests indicated their knowledge actually was in these areas.


The results of this project demonstrate that education provided by an APN with expertise in rehabilitation is an effective way to increase the knowledge of staff nurses about basic rehabilitation competencies. This project involved nurses learning through pre- and posttests and self-study modules developed by an APN on 15 basic rehabilitation competencies.

Explanation of Findings

Scores on 14 of the 15 competency areas were improved between the pre- and posttests. As statistical analysis revealed few other significant correlations, variables, or plausible explanations for the statistically significant increase in scores between pre- and posttests, the difference can reasonably be attributed to the educational intervention. The findings from this project are also supportive of and supported by prior studies that demonstrated that education increases knowledge in a specialty area (Carey, 2001; Kendall-Gallagher, 2008; Smolenski, 2007; Zulkowski, Ayello & Wexler, 2006).

The only competency area that did not show significant improvement from the educational intervention was disability, for which the mean pretest score was 95%. It is likely that the nurses working on this unit had enough experience and orientation to rehabilitation that they already possessed sufficient competency in the general area of disability.

Although there were few significant correlations, the ones that were moderately positive were correlated with variables that could explain some of this variance. For example, nurses who were older performed better on the pretest related to sexuality. A certain comfort level with this content could be gained from life experience. One might expect that years of experience as a nurse or higher levels of basic education would be positively correlated with a number of the competency areas pretests, but higher education only correlated with two of the pretests, and years of prior nursing experience was not significantly correlated to any of the pretest scores. The most interesting secondary finding was the significant negative correlation between the participants' ranking of their rehabilitation knowledge and certain pretest scores. This specific finding would suggest that the staff nurses overestimated their knowledge of rehabilitation, or perhaps were not aware of what they did not know. All of the data further support the idea that rehabilitation nursing does indeed have a set of unique skills and knowledge specific to this specialty area.

One surprising finding emerged. This author rather expected lower pretest scores in the area of dysphagia, as that is a problem often unique to rehabilitation patients, but this particular rehabilitation unit treated many patients with stroke who received speech therapy. It is likely that daily interaction and education of nursing staff by the two speech therapists on the unit may have positively influenced the pretest scores in the area of dysphagia. Indeed, the nurse manager confirmed that the speech therapists on the unit had provided education to the nursing staff and that many patients with dysphagia had been cared for on their unit. This may account for the higher than expected pretest scores from staff members in the area of dysphagia over some of the other rehab-specific competencies.

Implications for Rehabilitation Clinical Practice

Nurses new to the specialty of rehabilitation nursing require education in specific rehabilitation competencies. Interestingly, the results demonstrated that the number of years of prior nursing experience in other areas or even the months worked on the rehabilitation unit did not significantly influence the nurse's knowledge in most areas of rehabilitation. This finding supports the expectation that rehabilitation is a specialty with its own unique body of knowledge and suggests that nurses do require some additional knowledge that is better acquired through specific study than time spent working on a rehabilitation unit. It should be noted, however, that as the unit was less than one-year old, the nurse manager and outside organization who helped to set up the unit did try to educate the staff on pertinent rehabilitation knowledge. This was done informally as new staff members were oriented to the unit and also by posting informative articles and the like in common areas for staff to read.

The findings from this study suggest that staff nurses working in rehabilitation can gain knowledge through self-study of content about basic rehabilitation competencies. Education through self-study of basic competency content was the factor deemed most significant in advancing rehabilitation nursing staff knowledge.

Strengths and Limitations of the EBP Project

This project had several important strengths. The APN conducting the project was an experienced rehabilitation nurse and educator. The educational method for the project was negotiated between the APN and the nurse manager of the rehabilitation unit to fit the needs of the staff and promote participation. The intervention required no additional work time for the nurses nor extra meetings, so the intervention was cost-effective for the unit and yet helped them to meet accreditation standards by showing how the staff met basic competencies in their jobs. In addition, buy-in was obtained from the nurse manager and chief nursing officer (CNO) of the organization, so these key opinion leaders encouraged staff to accept the innovation. The nurse manager set a good example for her staff by also participating in the educational intervention, as suggested to her by the CNO. The DOI framework used for the project helped to guide the process and fit well with the intervention. Lastly, the nursing staff seemed motivated to learn and the data showed a significant increase in rehabilitation knowledge as measured by the pre- and posttest scores.

There are several significant limitations to this project that should be noted. First, the number of participants was small, ranging from 7 to 12 for each module, and not all of the nurses participated in all 15 modules, further decreasing the actual sample size for each competency. The expansion of sample size, the method chosen for the educational intervention, and the ability of the APN to meet with staff were all hindered by limited resources, a small staff on a small unit, many part-time employees, and time constraints. This project begs further research that would compare results of the educational intervention on two different units with larger numbers of full-time staff, and the difference of face-to-face education by an APN versus self-study modules. Additional items such as nurse perceptions or job satisfaction could be measured to determine other outcomes that might be affected by APN education of rehabilitation nursing staff. Lastly, the instrument used for the pre- and posttest was the ARN-CAT. The ARN-CAT has not been tested for reliability or validity, although it is the only tool readily available for similar use. Such data would lend credibility and support to use of the ARN-CAT as an instrument for future research projects.

Implications for the Future Research

Additional questions for further research arose during this project. Would the results be similar if a different tool rather than the ARN-CAT was used? The ARN-CAT provided correct answers and immediate feedback. Could nurses have improved their scores as significantly solely from taking and re-taking the ARN-CAT without the educational intervention in between? Is a self-study format as effective as face-to-face teaching? Could a similar educational design be used to assist nurses to achieve the knowledge needed for certification in rehabilitation nursing? How could a similar project be implemented on other units with rehabilitation nursing staff? What is the best way to share these or similar educational modules with other units? Might increased knowledge result in better job satisfaction? Additional research is needed to correlate nursing knowledge with improved patient outcomes and staff job satisfaction.

In conclusion, the best practice model recommendation was obtained through a search of the literature for relevant evidence. Best practice suggested that to increase staff knowledge, an educational intervention (as was done through this EBP project) was appropriate. The APN developed and implemented a series of 15 self-study modules on the basic competencies of rehabilitation as set forth by the ARN. Staff nurses who participated in the educational innovation (through a series of pre- and posttests with self-study modules in between) showed significant improvement in test scores. The EBP project answered the clinical question by demonstrating positive outcomes that staff nurses who were educated by an APN on basic rehabilitation competencies improved their knowledge in the specialty area over generalized nursing knowledge. In addition, several staff nurses participating in the project formed a study group to continue preparation to sit for the rehabilitation nursing certification examination when eligible, a demonstration of further positive outcomes.


The author gratefully acknowledges the wise guidance and assistance of Dr. Carole Pepa, PhD, RN, Professor of Nursing, Valparaiso University, Valparaiso, Indiana, advisor for this project.

Key Practice Points

  1. Rehabilitation nursing should be part of every basic nursing curriculum.
  2. Self-study modules can be effective in promoting knowledge of rehabilitation nursing.
  3. Rehabilitation nursing knowledge increased when staff nurses completed APN-developed modules on 15 basic competencies in rehabilitation nursing.
  4. The ARN-CAT provides a useful tool for measuring outcomes related to rehabilitation nursing knowledge.

Earn nursing contact hours

Rehabilitation Nursing is pleased to offer readers the opportunity to earn nursing contact hours for its continuing education articles by taking a posttest through the ARN website. The posttest consists of questions based on this article, plus several assessment questions (e.g., how long did it take you to read the articles and complete the posttest?). A passing score on the posttest and completing of the assessment questions yield one nursing contact hour for each article.

To earn contact hours, go to and select the “Education” page. There you can read the article again, or go directly to the posttest assessment by selecting “RNJ online CE.” The cost for credit is $10 per article. You will be asked for a credit card oronline payment service number.

The contact hours for this activity will not be available after April 30, 2015.

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