Barriers and facilitators to implementing a stepped care cognitive-behavioral therapy for insomnia in cancer patients: a qualitative study.

Abstract

Insomnia affects 30-60% of cancer patients and tends to become chronic when left untreated. While cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment, this intervention is not readily accessible. This qualitative study investigated current practices in the assessment and management of insomnia in five hospitals offering cancer care and identified the barriers and facilitators to the implementation of a stepped care CBT-I (i.e., web-based CBT-I followed, if needed, by 1-3 booster sessions) in these settings. Nine focus groups composed of a total of 43 clinicians (e.g., physicians, nurses, radiation therapists, psychologists), six administrators, and 10 cancer patients were held. The Consolidated Framework for Implementing Research (CFIR) was used to develop the semi-structured interview and analyze the data. Sleep difficulties are not systematically discussed in clinical practice and when a treatment is offered, most often, it is a pharmacological one. Barriers and facilitators to the implementation of a stepped care CBT-I included individual characteristics (e.g., lack of knowledge about CBT-I); intervention characteristics (e.g., increased accessibility offered by a web-based format); inner setting characteristics (e.g., resistance to change); and process factors (e.g., motivation to offer a new service). This qualitative study confirms the need to better address insomnia in routine cancer care and suggests that, while some barriers were mentioned, the implementation of a stepped care CBT-I is feasible. Keys to a successful implementation include accessibility, training, inclusion of stakeholders in the process, and ensuring that they are supported throughout the implementation.