Date of Award


Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Jane Dixon


The purpose of this doctoral project was to develop and pilot an expert-panel validated training program specifically for nurse practitioners (NPs) in remote settings, and to evaluate how new remote NPs rate their self-efficacy (a measure of confidence) in performing specific advanced clinical skills and procedures (ACSPs) before and after completing this program. The practice of primary care in remote regions requires expanded clinical skills for high acuity scenarios given the isolation. With more new primary care NPs practicing in more remote locales, their preparation for performing ACSPs, (including in complex and high-acuity cases) is critical for safe and effective care. Such skills are not uniformly taught in academic programs, but are easily imparted via additional training and practice. After an extensive literature review and interviews with stakeholders, we compiled a list of ACSPs and utilized a diverse expert panel to validate the skills to be included in a pilot training program. After achieving consensus, the hybrid online-in-person curriculum was developed using standards from the International Nursing Association for Simulation and Clinical Learning. This training was conducted over 2 days using a “flipped classroom” hybrid model, and delivered to a class of 15 primary care NPs in their last year of their programs, who were bound for remote practice. All participants completed a pre and post-participation survey to assess their self-report of self-efficacy using a modified, validated questionnaire. Our expert panel process achieved consensus (>63% of respondents rating a skill as “very important” to the remote NP) and was successful at rank-ordering the skills amassed by our literature review. After implementation of the pilot, we observed significant increases in reports of confidence. Across all tasks, participants reported significantly higher confidence following training, as indicated by an increase in difference in mean scores from 1 to 6.15. For all tasks, differences were statistically significant by both a paired T-test and a Whitney-Mann U test with probability of .01 or less. Our data indicates that the methods utilized (i.e., increased psychomotor practice in ACSPs), increases confidence in new nurse practitioners, and suggests that the amount of time spent in practice is associated with interval increases in confidence. A combination of didactic and hands-on, psychomotor methods was found to be uniformly effective at increasing confidence, and thereby self-efficacy, and higher success is associated with more time practicing the kinesthetic skills in situ. As the NP becomes a more critical player in the provision of remote primary care in the US, further training in skills needed for remote practice may decrease morbidity, mortality and health care expenditure. Further exploration is needed to track longitudinally how these new NPs rate their self-efficacy as they gain more experience in the field, and likewise with more comprehensive training programs.

Open Access

This Article is Open Access