Date of Award


Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Dr. Bethany Rolfe Witham

Faculty Reader

Dr. April Morgenroth

Executive Summary

Executive Summary

Background & Significance: Rural communities, comprised of over 51 million people in the US, face a detrimental barrier and lack of access to healthcare (Douthit, Kiv, Dwolatzky, Biswas, 2015; Ford et al., 2018; Stuhlmiller & Tolchard, 2018). Outpatient registered nurses (RNs) are essential to the free, outpatient clinics that seek to overcome this barrier. When outpatient RNs function to their full scope of education, patient outcomes are improved, clinic efficiency is increased allowing for enhanced workflow and higher patient volume, and both healthcare provider satisfaction and patient satisfaction are improved (Bodenheimer & Bauer, 2016; Smolowitz et al., 2015). While outpatient nursing organizations and guides exist, nursing programs emphasize inpatient care and often neglect outpatient nursing education (Smolowitz et al., 2015). This educational gap must be addressed if RNs are to be equipped to practice to their full scope of education in outpatient settings and meet the needs of rural populations.

Problem & Purpose Statements: Volunteer RNs at a small, free clinic serving a rural area in Washington State were unclear regarding their role and scope of practice in the outpatient setting. For the clinic to be sustainable, reach the targeted population, and retain volunteers, RNs must function confidently at their full scope of practice. The purpose of this project was to develop and implement an evidence-based toolkit addressing the role and responsibilities of volunteer outpatient RNs practicing at the rural clinic.

Methods: Utilizing Bandura’s Theory of Self-Efficacy (1977) and the Institute for Healthcare Improvement’s Plan-Do-Study-Act Cycle framework, a quality improvement project was performed. An educational toolkit providing continuing education for RNs regarding outpatient nursing was developed. A mixed-methods evaluation measured the efficacy of the toolkit with a pre-survey and post-survey completed by participants. Likert-style questions measured RN self-efficacy levels regarding specific outpatient nursing tasks. Open-ended survey questions allowed for free-write answers eliciting participant feedback.

Results/Outcomes: While quantitative data provided mixed results, qualitative data strongly suggests that self-efficacy increased after the RNs reviewed the toolkit. Mixed quantitative results could be related to limited sample size and anonymity of the survey, which could have resulted in data from different participants in the pre-test and post-test. Another consideration is the Dunning-Kruger effect, which proposes that increase in knowledge may result in more realistic view of one’s expertise (Dunning, 2011). Despite ambiguity of the quantitative results, the qualitative results strongly indicate that the educational toolkit was helpful, user-friendly, and successful in increasing nursing confidence in outpatient practice.

Sustainability: The clinic was provided a summary of the project results, suggestions for improvement of the educational toolkit, and the recommendation to appoint a staff member to annually update the toolkit. The toolkit was made available online to all clinic volunteers. Utilizing a modifiable website format for the toolkit provided clinic management the ability to update and add material as needed. The sustainability of this project depends on its ability to remain up to date in the ever-evolving healthcare world.

Implications: This quality improvement project proposes that online educational toolkits are a cost-effective, practical means by which continuing education can be provided and RN self-efficacy in outpatient practice can be augmented. While effective in a small, rural clinic, future studies are needed to confirm the efficacy in other settings and to evaluate the long-term outcomes of educational toolkits. The project also highlighted a gap in current RN education. An immediate solution is to provide and require outpatient RNs to complete continuing education material such as the toolkit. Ultimately, nursing education must be restructured to increase content addressing outpatient care. RNs have a valuable role in the outpatient setting, and the current educational system does a disservice to RNs, outpatient care teams, and patients by not adequately preparing nurses for the outpatient setting.


Bodenheimer, T., Bauer, L. (2016). Rethinking the primary care workforce – an expanded role for nurses. New England Journal of Medicine, 375(11).

Douthit, N., Kiv, S., Dwolatzky, T., Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public Health, 129(6), 611–620. Doi:

Dunning, D. (2011). The dunning-kruger effect: On being ignorant of one’s own ignorance. Advances in Experimental Social Psychology, 44. doi: 10.1016/B978-0-12-385522.0.00005-6

Ford, C., R., Sawyer, P., Brown, C., J. (2018). Utilizing geriatrics-focused web-based continuing education to reach practitioners in rural practice. TechTrends, 62(3), 286-295. Doi: 10.1007/s11528-018-0258-9

Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., & Wood, L. (2015). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130–136. Doi: 10.1016/j.outlook.2014.08.004

Stuhlmiller, C. M., & Tolchard, B. (2018). Population health outcomes of a student-led free health clinic for an underserved population: A naturalistic study. Journal of Community Health, 43(1), 193–200. Doi: 10.1007/s10900-017-0402-z