Factors to Improve Reverse Integration: A Mixed Method Embedded Design Study.

Individuals with serious mental illness face inequity in receiving primary care services. The Substance Abuse and Mental Health Services Administration (SAMHSA) granted funds to Certified Community Behavioral Health Clinics (CCBHC) to integrate primary care and behavioral health specialties to increase access to care. This mixed method study aimed to measure the SAMHSA-defined levels of reverse integration at a CCBHC at one point in time. Providers and patients provided feedback through semi-structured interviews. Qualitative data was investigated for themes, while the quantitative data was run through inferential analysis with the Kruskal Wallis H test. Clinically meaningful results showed people using primary care at the integrated clinic were more satisfied and were more apt to continue seeing their current providers than those receiving non-integrated care. The CCBHC achieved level 4 integration; factors investigated confirmed proximity alone does not necessitate integration without effective communication and implementation of practice changes.

Feasibility, Acceptability, and Intervention Description of a Mobile Health Intervention in Patients With Heart Failure.

Mobile health (mHealth) is used to encourage and support self-management skills in patients with heart failure. The purpose of the study was to describe the feasibility, fidelity, usability, and acceptability of mHealth interventions. This pilot study used a randomized 3-group (enhanced usual care, mHealth, and mHealth plus, which included a nurse practitioner and community health worker) repeated-measure design to determine the feasibility of using a self-management behavior app and a Bluetooth-enabled scale for daily self-monitoring of weights and medications. In the 2 mHealth groups, of the 48 patients, 38 (79%) engaged partially in recording daily weights and medications, and of the 74 patients in the sample, we obtained partial to complete data on 63 (85%) of the patients during follow-up outcome phone calls. Most patients found the intervention to be feasible, usable, and acceptable, and (93%) patients in the mHealth group and 100% of patients in the mHealth plus group agreed or strongly agreed that they learned how to self-manage their heart failure using the app. The intervention was reasonable to implement and provided insight for future intervention improvements.

Cardiovascular Disease Risk in Rural Adults: A Pilot Intervention Study Using Registered Nurse/Community Health Worker Teams.

BACKGROUND: Cardiovascular disease (CVD) risk reduction programs led by a nurse/community health worker team are effective in urban settings. This strategy has not been adequately tested in rural settings. OBJECTIVE: A pilot study was conducted to examine the feasibility of implementing an evidence-based CVD risk reduction intervention adapted to a rural setting and evaluate the potential impact on CVD risk factors and health behaviors. METHODS: A 2-group, experimental, repeated-measures design was used; participants were randomized to a standard primary care group (n = 30) or an intervention group (n = 30) where a registered nurse/community health worker team delivered self-management strategies in person, by phone, or by videoconferencing. Outcomes were measured at baseline and at 3 and 6 months. A sample of 60 participants was recruited and retained in the study. RESULTS: In-person (46.3%) and telephone (42.3%) meetings were used more than the videoconferencing application (9%). Mean change at 3 months differed significantly between the intervention and control groups for CVD risk (-1.0 [95% confidence interval (CI), -3.1 to 1.1] vs +1.4 [95% CI, -0.4 to 3.3], respectively), total cholesterol (-13.2 [95% CI, -32.1 to 5.7.] vs +21.0 [95% CI, 4.1-38.1], respectively), and low-density lipoprotein (-11.5 [95% CI, -30.8 to 7.7] vs +19.6 [95% CI, 1.9-37.2], respectively). No between-group differences were seen in high-density lipoprotein, blood pressure, or triglycerides. CONCLUSIONS: Participants receiving the nurse/community health worker-delivered intervention improved their risk CVD profiles, total cholesterol, and low-density lipoprotein levels at 3 months. A larger study to explore the intervention impact on CVD risk factor disparities experienced by rural populations is warranted.

"The constant worry": Urinary incontinence self-management in rural women: A qualitative study.

Urinary incontinence (UI) is experienced by approximately 60% of women in the United States and has a negative impact on self-esteem, sexual function, social participation, and quality of life. Rural women, who are underrepresented in the UI literature, face many health disparities and unique barriers to accessing care. The purpose of this qualitative descriptive study was to explore UI self-management behaviors in rural women with UI, including the contextual factors that influence their approach to self-management. This study recruited rural women, ages 30-60 years, using purposive sampling via social media. Demographic information was collected. A semi-structured interview guide was used to conduct individual, in-depth interviews via Zoom. Interview data were analyzed using qualitative description. Sections of interview text were coded using a priori and emergent codes, grouped into categories, and distilled into themes. A total of 31 participants (mean age = 47.2 years) met inclusion/exclusion criteria, enrolled, and completed the study. Qualitative analysis revealed rural as a cross-cutting theme and five major themes: self-management behaviors, familial influence, medical encounters, talking about UI, and resource scarcity. Participants described the rural environment as having a substantial impact on their approach to UI self-management. Specifically, rural social enmeshment made seeking care for UI in rural communities challenging. Findings shed light on how the rural environment influences various aspects of UI self-management in midlife women. Diverse perspectives in UI self-management are needed to advance knowledge in this field.

Quality improvement: Antimicrobial stewardship in pediatric primary care.

BACKGROUND: Antimicrobial resistance is the resistance of microorganisms to antibacterial, antiviral, antiparasitic, and antifungal medication resulting in increased healthcare costs with extended hospital stays in the United States. The goals of this quality improvement project were to increase the understanding and importance of antimicrobial stewardship by nurses and health care staff and increase pediatric parents'/guardians' knowledge of the proper use of antibiotics and differences between viruses and bacterial infections. METHODS: A retrospective pre-post study was conducted in a midwestern clinic to determine if an antimicrobial stewardship teaching leaflet increased parent/guardian antimicrobial stewardship knowledge. The two interventions for patient education were a modified United States Center for Disease Control antimicrobial stewardship teaching leaflet and a poster regarding antimicrobial stewardship. RESULTS: Seventy-six parents/guardians participated in the pre-intervention survey, with 56 being included in the post-intervention survey. There was a significant increase in knowledge between the pre-intervention survey and the post-intervention survey with a large effect size, p < .001, d = 0.86. This effect was also seen when comparing parents/guardians with no college education, who had a mean knowledge increased change score of 0.62, to those parents/guardians with a college education, whose mean knowledge increase was 0.23, p < .001 with a large effect size of 0.81. Health care staff thought the antimicrobial stewardship teaching leaflets and posters were beneficial. PRACTICE IMPLICATIONS: The use of an antimicrobial stewardship teaching leaflet and a patient education poster may be effective interventions for improving healthcare staff's and pediatric parents'/guardians' knowledge of antimicrobial stewardship.

Influencing a Culture of Quality and Safety Through Huddles.

BACKGROUND: Literature shows that interdisciplinary huddles help promote clear communication and proactive reporting of potential errors. LOCAL PROBLEM: High reliability organization (HRO) and just culture models were implemented, yet fragmented team communication about patient safety remained. Huddles were implemented to identify and address patient safety issues. METHODS: A pre/postintervention design was used. Near-miss and actual event safety metrics, patient satisfaction, and employee satisfaction/work group perceptions were measured at 3 time points over 1 year. INTERVENTIONS: Daily interdisciplinary huddles were implemented to improve communication, reduce errors, and improve patient and employee satisfaction. RESULTS: Near-miss reporting increased across time points. Patient satisfaction with how the staff worked together to provide care significantly increased over time. Employee satisfaction and perception of work group communication, collaboration, and psychological safety scores improved, however, were not statistically significant. CONCLUSION: Implementing huddles demonstrated improved outcomes in patient safety, patient satisfaction, and employee satisfaction/work group perceptions.

Tai Chi as a Complementary Therapy for Depression and Anxiety Among U.S. Veterans in a Mental Health Inpatient Setting.

BACKGROUND: Depression and anxiety are two of the top five mental illnesses veterans report. Treatment for depression and anxiety includes medications and psychiatric treatment in inpatient, outpatient, and residential treatment programs; the use of complementary and alternative medicine (CAM) can have beneficial results by decreasing symptoms, recognize patients' preference for CAM, and be cost-effective. AIM: This study aimed to evaluate the effects of Tai Chi on depression and anxiety symptoms on inpatient psychosocial or substance use disorder (SUD) rehabilitation treatment program residents since little evidence exists regarding the effectiveness of Tai Chi on participants in residential mental health treatment programs. METHOD: A mixed-method, cohort design with 88 participants (41 usual treatment without Tai Chi, 47 intervention) used a demographic survey, Hamilton Anxiety Scale, Quick Inventory of Depressive Symptomatology, self-report, and the Patient Health Questionnaire-9 at Weeks 1 and 4 of the treatment program. After Week 4, the intervention group responded to six open-ended questions about Tai Chi's effects on their overall depression and anxiety. RESULTS: The anxiety level of the intervention group was significantly decreased, as evidenced by the Hamilton Anxiety Scale scores (p = .02). However, the measures of depression did not differ between the groups. Two themes, mindfulness and satisfaction, were identified from the written responses regarding the Tai Chi intervention. CONCLUSION: Tai Chi effectively reduced symptoms of anxiety that varied by age and ethnicity. This study increased the insight regarding the benefit of including Tai Chi as a complementary therapy for those participating in residential treatment programs.

mHealth Intervention to Improve Cardiometabolic Health in Rural Hispanic Adults: A Pilot Study.

BACKGROUND: Hispanic/Latino adults have high rates of hypertension, obesity, and type II diabetes. Mobile health technologies (mHealth) are effective in supporting self-management of lifestyle behaviors; however, the effectiveness in rural Hispanic/Latino adults is unclear. OBJECTIVE: A pilot 12-week self-management mHealth intervention in rural Hispanic/Latino adults with cardiometabolic risk was conducted. METHODS: A randomized, 2-group (intervention and enhanced usual care) design was used to test the use of the MyFitnessPal app, a smart scale, and text messages to support daily self-monitoring of weight, food intake, and steps. RESULTS: Seventy participants enrolled. The intervention group had greater improvement in body mass index ( P = .052) and waist circumference ( P = .043) at 12 weeks and a trend toward greater fitness at 12 and 24 weeks. Both groups improved hemoglobin A 1c level at 12 and 24 weeks. CONCLUSIONS: mHealth using MyFitnessPal, smart scale, and text messages may be effective for improving aspects of cardiometabolic health in rural Hispanic/Latino adults.

Mobile Health Self-management Interventions for Patients With Heart Failure: A Pilot Study.

BACKGROUND: Heart failure (HF) is a multifaceted syndrome that requires self-management for adherence to treatment to control symptoms. Symptoms need to be monitored to prevent impending HF exacerbations. Few HF study authors have assessed efficacy of mobile health (mHealth) interventions particularly with virtual visits to evaluate outcomes such as symptoms and healthcare utilization. OBJECTIVE: The aim of this pilot study was to evaluate the potential effect of mHealth self-management interventions on symptom status and health-related quality of life and describe health care utilization in patients with HF. METHODS: This 3-month pilot study included 74 patients with HF and used a randomized 3-group repeated-measures design (enhanced usual care, mHealth, and mHealth plus [+] virtual visits). Surveys included the Heart Failure Symptom Survey, EuroQol, and a specialized phone application for patients to report weights and medications. RESULTS: The mHealth groups had an overall decrease in most symptom severity and frequency, particularly shortness of breath. Compared to enhanced usual care, both the mHealth+ and mHealth groups showed promise with medium effect sizes (range .55-.60) in relation to shortness of breath and a medium effect (.51) for lower extremity edema for the mHealth+ group. There was a trend toward improvement in health-related quality of life in both intervention groups at month 3. The mHealth+ group had fewer rehospitalizations. CONCLUSIONS: In general, both mHealth groups fared better on symptoms and health care utilization. Small to medium effect sizes on selected symptom outcomes warrant this study to be conducted in a fully powered study. Virtual visits may assist in symptom recognition and self-management.

Nurse and Provider Pain Management Education Priorities and Barriers.

BACKGROUND: The purpose of this research was to describe health care nurse and providers' pain management education priorities and barriers for pediatric cardio-thoracic surgical (CTS) patients and their caregivers. DESIGN: This was a qualitative-descriptive study design using survey methodology. METHODS: A convenience sample of 206 (CTS) health care professionals including 172 nurses, 11 advanced practice providers, and 23 physicians were invited to participate in this study. The survey was distributed through a work e-mail within a 145-bed tertiary pediatric hospital and focused on collaborative pain management educational priorities and barriers. RESULTS: Of the 206 cardio-thoracic service health care nurses/providers surveyed, 45.6 % (N = 94) responded to the survey. The top pain management education priority for these nurses/providers included immediate postoperative pain management knowledge for the caregiver and pediatric CTS patient. The lowest priority 13.8% (N = 13) included education related to pain management needs after discharge. Of the 94 nurses/providers who responded, 31.9% (n = 30) identified the presence of timing and communication barriers in providing pain management education with caregivers and pediatric CTS patients. AIMS: The aim of this research was to describe health care providers pain management education priorities and barriers for cardio-thoracic surgical (CTS) pediatric patients and their caregivers. SETTING: 145-bed tertiary pediatric hospital. PARTICIPANTS/SUBJECTS: Nurses, advanced practice providers [APP's], and physicians. CONCLUSIONS: Nurses and providers prioritize immediate postoperative pain management education; however, there remains a need to focus more on the outcomes of pain management education for caregivers and pediatric CTS patients after discharge.

Secondary analysis of YFAS 2.0 symptom counts, impairment/distress, and food addiction severity in adults with overweight/obesity.

PURPOSE: Understanding the complexities of obesity is important for developing effective interventions. Evidence is growing that addictive-like tendencies toward foods may contribute to obesity in some individuals. The Yale Food Addiction Scale (YFAS, YFAS 2.0) was developed to identify individuals with addictive-like eating behaviors. Diagnosing food addiction (FA) requires meeting a symptom threshold plus clinically significant impairment/distress (self-perceived), but the utility of the impairment/distress criteria remains controversial. This secondary analysis compared individuals who did not meet the FA symptom criteria, met the symptom, but not the impairment/distress criteria, and met both criteria. METHODS: This secondary analysis of data from a randomized controlled pilot study involving 83 adults with overweight/obesity used descriptive statistics and Univariate ANOVAS to compare YFAS 2.0 and Weight and Lifestyle Inventory responses among the groups. RESULTS: Twenty-eight individuals did not meet the FA symptom criteria, 20 met the symptom, but not the impairment/distress criteria, and 35 met both criteria. Of the latter, 80.0% had severe, 8.6% had moderate, and 11.4% had mild FA. Age at onset of overweight was lower with severe than with mild FA (p = 0.023). CONCLUSIONS: The YFAS 2.0 identified a distinct group with severe FA and a group who met the FA symptom threshold, but not the impairment/distress criteria. Few participants perceived impairment/distress unless they endorsed ≥ 6 symptoms. Adding clinical interviews may aid in assessing impairment/distress and addictive-like eating behaviors, particularly in those meeting the FA symptom, but not the impairment/distress criteria. Better characterization of these groups may help targeting obesity interventions. TRIAL REGISTRATION NUMBER: NCT03431831, 1/30/2018. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Parents' Perceptions of Health-Related Quality of Life of Children Diagnosed with Osteogenesis Imperfecta.

PURPOSE: The purpose of this research was to describe the health-related quality of life (HRQoL) perceptions of parents of children diagnosed with osteogenesis imperfecta (OI). DESIGN AND METHODS: This research used a descriptive design with a comparative sample. The Child Health Questionnaire (CHQ-PF 28) parent form was used to assess HRQoL in a sample of 37 parents from a mid-western tertiary pediatric hospital OI specialty clinic. Comparisons were made with a sample of parents of well children. RESULTS: Parent HRQoL perception scores were described in both the physical and psycho-social-emotional domains. The domains of physical function (PF), bodily pain (BP), general health (GH), parent impact-emotional (PE), and child self-esteem (SE) were the lowest HRQoL mean domain scores for the parents of the children diagnosed with OI. Ceiling and floor scores were calculated to describe the magnitude of the differences between the mean HRQoL perception domain scores of the two parent groups. CONCLUSIONS: Low HRQoL physical and psycho-social-emotional mean domain scores in conjunction with small percentage scores in the ceiling (and greater percentage scores in the floor) for parents of children diagnosed with OI were described. Findings suggest the on-going need for research to identify interventions to promote physical functioning for the child diagnosed with OI. Outcome based programs for parent and family-centered psycho-social self-care should be developed. PracticeImplications: ip Comprehensive and longitudinal assessment of HRQoL for both parents and their children diagnosed with OI will assist in documenting the outcomes of interventions for the management of chronic care.

Historical Trauma, Ethnic Experience, and Mental Health in a Sample of Urban American Indians[Formula: see text].

BACKGROUND: Historical trauma (HT) among American Indians (AIs) has been linked with poor mental health but has been inadequately studied among urban populations. OBJECTIVES: The purpose of this study was to describe historical trauma, historical loss associated thoughts, ethnic experience, and psychological symptoms among a population of urban AIs. METHOD: This was a mixed methods study. In addition to focus groups, survey participants were administered the Historical Losses Scale, the Historical Losses Associated Symptoms Scale, the Scale of Ethnic Experience, and the Achenbach System of Empirically Based Assessment Adult Self-Report. Rates of psychological symptoms were compared with matched controls from a normative data set. RESULTS: Participants reported a strong sense of ethnic identity, a moderate desire to associate with other AIs, moderate comfort within mainstream society, and moderately high perceived discrimination. The most common HT themes were loss of culture, respect by children of traditional ways, and language. Compared with controls, participants had higher rates of aggressive behavior, substance use, thought problems, and obsessive symptoms, but some of these issues are likely explained by cultural factors. A greater number of participants met the clinical threshold for multiple problems compared with controls. CONCLUSIONS: This sample of AIs reported frequent experiences of discrimination. HT is a significant factor in the lives of many urban AIs who also have significantly higher rates of a number of mental health problems. Providers must be aware of these issues to provide the most effective care to AIs.

Implementation of a Nursing Based Order Set: Improved Antibiotic Administration Times for Pediatric ED Patients with Therapy-Induced Neutropenia and Fever.

PURPOSE: For patients with chemotherapy-induced neutropenia and fever, delays in antibiotic administration are associated with poor outcomes, such as ICU admission and need for further interventions. The objective of this quality improvement project was to significantly reduce the time from initiation of triage to antibiotic administration for pediatric patients arriving to the emergency department with therapy-induced neutropenia and fever. METHODS: An interdisciplinary team set an evidence-based goal for time to antibiotics (TTA) at 60-min. A six-month retrospective chart review of Emergency Department (ED) patients revealed a 128 min TTA mean when measured from the initiation of triage to antibiotic administration, which also reflected 0% of patients receiving antibiotics within the goal of 60 min. Members of the interdisciplinary team evaluated delays in patient care workflow and identified three primary interventions to decrease the TTA. These three evidenced-based interventions were implemented and evaluated using the Plan-Do-Check-Act (PDCA) quality improvement methodology. RESULTS: By the end of the implementation period mean TTA improved to 53 min and patients received antibiotics within 60 min (83% of the time). CONCLUSION: The interventions focused on both provider and nursing workflow, however the implementation of an evidence-based practice nursing order set made the greatest impact on timeliness of antibiotic delivery time.

Implementing a Peer Support Network to Promote Compassion Without Fatigue.

OBJECTIVE: The aims of this study were to implement a Peer Support Network (PSN) pilot project including education/training, peer support, and resiliency training and to explore how interventions impact compassion satisfaction (CS) and compassion fatigue (CF) in a community hospital. BACKGROUND: CF has been reported to negatively affect nurse retention. The PSN provides a 3-tiered team approach to enhance CS and support nurses experiencing CF symptoms. METHODS: Twenty nurses participated in PSN training and completed preimplementation and 6-week postimplementation surveys: Professional Quality of Life, Compassion Practice Instrument, and self-care resource utilization. RESULTS: Statistically significant improvements in CS and nonstatistical improvements in CF were found. CONCLUSION: Promoting a PSN may increase CS and potentially prevent work-related physical, emotional, social, and intellectual CF sequelae.

Identification of populations at risk: Stillbirth toolkit for health care providers.

BACKGROUND: Maternity care and women's health are measured, in part, by the stillbirth rate of a country. The purposes of this pilot project were to: a) establish a baseline of health care provider knowledge regarding stillbirth risk factors based on geographic distribution (urban/rural) and provider licensure (MD, APRN, PA, CNM) and b) evaluate the utility of a Stillbirth Risk Factor Toolkit and its effects on provider knowledge. METHODS: Evaluative research using a retrospective pre-posttest survey design was completed. The study setting included primary care clinics (urban [n=25] and rural [n=25]) in Nebraska. Health care providers from N=50 clinics were surveyed about their knowledge of stillbirth risk factors (modifiable and non-modifiable) before and after reading the Toolkit. RESULTS: Providers were least knowledgeable regarding the definition of stillbirth and the number of weeks' gestation that constitute a stillbirth. Overall, there was no significant difference in baseline knowledge between rural and urban providers. Nearly half (43.8%) found the Toolkit to be very helpful and applicable to their patient population, and 34.8% said they would be very likely to utilize it with their patients. There was a statistically significant increase in knowledge of stillbirth risk factors among all health care providers after reviewing the Toolkit (p<0.001). CONCLUSIONS: Health providers had varied baseline knowledge about stillbirth. The Toolkit improved provider knowledge, but further research is needed to assess its impact on clinical practice.

A retrospective review of patient outcomes in the pediatric HEROES weight management program.

Pediatric obesity is a public health concern in the U.S. The purpose of this study was to describe the impact of a pediatric stage 3 and 4 weight management program. Program aims measured: change in biometric values using BMI z-scores; intervention attrition rate; and health-related quality of life (HRQOL) from admission through the initial six months of the program. The program evaluation included a retrospective review of 884 electronic records. Of the 698 children that met the inclusion criteria, 468 completed at least one follow-up visit within the baseline to 6 month time period. Overall 66.38% of the 468 maintained program involvement at the 6 month evaluation. Of the 468 who completed the 6 months, 192 children/families participated in the clinic only program and 276 participated both in the clinic and a 12 week contract education/fitness and exercise intervention. The completion rate for the contract intervention was 7.3%. All children demonstrated a decrease in BMI z-scores. There were no statistically significant differences (p = 0.276) in the BMI z-change scores from baseline to 6 months in the clinic only program; those who did not complete the education/fitness and exercise intervention, and those who completed the education/fitness and exercise intervention. Children demonstrated a statistically significant improvement in their overall HRQOL scale score (p = 0.001) from baseline to the 6 month evaluation. The results indicate the impact of attrition and HRQOL in weight management programs. Further research is needed to develop and strengthen the effectiveness of weight management interventions.

The Effect of Team Configuration on the Incidence of Adverse Events in Pediatric Critical Care Transport.

OBJECTIVE: Specialty pediatric transport teams are widely used for pediatric interfacility transport in the United States, with little industry consensus on optimal team configuration. The aim of this study is to assess the quality of the nurse/paramedic specialty team configuration as indirectly measured by the rate of adverse events in these transports. METHODS: Retrospective analysis of pediatric transport data from a hospital-based dedicated pediatric/neonatal transport team was conducted for patients transported in 2016. Data were categorized by general characteristics of transport and analyzed for the occurrence of adverse events. RESULTS: Five hundred sixty-four cases were analyzed. Cases were described by team configuration and then by transport mode, duration, time, patient age and acuity, and disposition. The overall rate of adverse event incidence was 8.3%, chiefly centered in device and process domains. There was no significant difference in the rate of adverse events between team configurations. CONCLUSION: There was no significant difference in the rate of adverse event occurrence in nurse/paramedic team configurations versus nurse/nurse configuration. Using critical care paramedics on pediatric transport teams enables a larger volume of patients to be transported to definitive care without concerns for decrease in quality or safety.

The Development and Implementation of a Forensic Education Module for Nebraska Critical Access Providers: A Pilot Study.

BACKGROUND: Sexual assault, intimate partner violence, and human trafficking are traumatic events for individuals and communities. As healthcare shortages increase, critical access hospitals must manage resources to ensure comprehensive forensic care effectively. Current literature indicates a lack of forensic healthcare education for providers within critical access hospitals. This forensic education module for critical access healthcare providers aimed to (a) increase forensic examination competencies, (b) improve forensic interviewing skills, (c) increase provider self-efficacy, and (d) show knowledge retention. METHODS: This mixed-methods pilot study utilized a convenience sample of 45 healthcare providers in Nebraska critical access hospitals who presented for the forensic education module training. Repeated measures analysis of variance and paired t tests assessed the aims of this study. Structured surveys gathered qualitative data on three themes. RESULTS: Implementation of the forensic education module showed a statistically significant increase in forensic interviewing skills, nonstatistically significant changes in general self-efficacy, and sustainability of knowledge and self-efficacy over 6 weeks. Analysis also showed a clinically significant increase in provider self-efficacy over 6 weeks. Structured questionnaire responses showed participants valued the content to address their perceived barriers to providing care. CONCLUSIONS: This study validates the need for increased education in Nebraska's rural and medically underserved areas to ensure access to forensic care and provision of services. This pilot study shows the potential for forensic education interventions to increase provider competencies and improve provider self-efficacy, with evidence of retention of knowledge and skills.