Barriers and facilitators to implementing a stepped care CBT-I in cancer clinics were grouped into larger domains based on the CFIR model: 1) characteristics of individuals; 2) intervention characteristics, 3) inner setting; and 4) process ((22), https://cfirguide.org).
Characteristics of Individuals
Knowledge and beliefs about CBT-I. CBT-I is an effective treatment and an additional tool to offer to cancer patients who have difficulty sleeping, but it does not appear to be very well known by cancer care providers in general and remains underutilized.
I think maybe it’s more a combination of the two, medication combined with a therapy, which in my view, should be the best (Social Worker).
I think it’s not yet as well-known as one would like, psychotherapy for sleep works very well, in that regard there is still a lot of work to make people aware of it (Psychologist).
Comorbidity. Participants, particularly psychologists, stated that it might be a challenge to take into account the common comorbidity of insomnia with other psychological disorders and pain.
Insomnia and sleep disturbances don’t just present by themselves (Psychologist).
It’s a very structured treatment. In real life insomnia or sleep disturbances don’t just present by themselves…you need to be very flexible in terms of how you intervene (Psychologist).
Motivation. Some cancer care providers discussed the degree of motivation participants would need to complete and adhere to a stepped care CBT-I beginning with an Internet-based (entirely self-administered) CBT-I. The intervention requires significant lifestyle changes and one must be prepared to make the effort to put the strategies into practice.
It will depend on the people, on how motivated they are…the intensity of their insomnia, I think, will also influence their motivation (Social Worker).
Sure it’s a bit harder to take the trouble of going on the Internet and doing the modules every week, for six weeks than to say I’m going to see a psychologist every week for six weeks. It takes more discipline (Nurse).
But you have to be ready to want to do that. You have to go when you feel like it. If you go but you don’t really want, that isn’t pleasant. You have to pick the right moment when you most feel like it (Patient).
Preferences. The importance of taking patients’ preferences into account was also mentioned as an important factor by the health care providers. For instance, patients who want a rapid solution to their problem would probably be better off if offered a pharmacological intervention.
Of course, you have to respect peoples’ preferences, some will want the quickest solution and they also won’t have the energy to invest in therapy (Psychologist).
Intervention Characteristics
Accessibility. On one hand, the lack of knowledge and access to the Internet was reported as a critical barrier for a stepped care CBT-I whose first step is an internet-based intervention. This barrier is likely to affect the involvement of patients living in remote areas, older people, and those with a low literacy (including health literacy) and lower socioeconomic status. This should be taken into account when thinking about referring the patient to the program.
You’ll also need to target a certain clientele, because there are patients who aren’t on the Internet or who are illiterate or who can’t read, who don’t know how computers work (Nurse).
I think there’s a certain segment of our clientele who are quite elderly…they’re likely to feel less comfortable or attracted by that (Social Worker).
Maybe not everybody is able to access it and has the knowledge (Patient).
On the other hand, the proposed intervention was perceived as highly accessible in the sense that it is simple to use and easy to understand, while being less costly for the organization. Moreover, the possibility to complete the treatment program at home, at a time and pace convenient for the patients, was identified as one of the clear advantages of the web-based CBT-I. Also, some patients who already have several medical appointments may refuse a psychological intervention because of transportations issues and some may have less energy to engage in a face-to-face intervention.
Personally, I found it very accessible. For anybody, it’s simple and easy to understand (Patient).
The clientele it reaches, access is easy, once it’s up and running, it no longer costs anything (Social Worker).
Even for somebody undergoing treatment, they can take it in small steps. They can watch it whenever they want, watch it again if they want (Patient).
The advantage is that the patient won’t have to go anywhere. Already there are some…who are very reluctant to travel, they already have a lot of appointments…(Nurse Navigator).
Short and long-term beneficial effects and impact on quality of life. Participants, especially patients and psychologists, emphasized the greater efficacy of CBT-I over pharmacotherapy and praised the long-term effects of CBT-I and its overall beneficial effect on quality of life.
In any case I find it more effective. As someone who has already taken anxiolytics, personally, I felt numb the next morning (Patient).
Psychological therapy is a lot better. Sure it’s longer, but it lasts over time and the strategies remain (Patient).
It’s just as effective as medication if you take the two by themselves… for example, the great thing about therapy, of course, for anyone who is willing to commit themselves to it, because doing therapy is, in fact, demanding, is that the gains remain over the long term, so medication might serve as a band aid, but as soon as you stop, the bad habits are still there, with therapy the changes are more sustainable over time (Psychologist).
We know that sleep has an impact on the quality of life, mood, anxiety and a lot of things (Psychologist).
Inner Setting
Time and resources. On one hand, the lack of time and resources, both human and material, emerged as a major possible barrier to implementation. Stakeholders expressed their concern that the implementation of CBT-I in their clinical setting would increase the overload that they were already experiencing. Some also mentioned that the additional costs for hospitals could be another barrier.
Somehow staff will need enough time to do it, in other words, there should be enough resources (Administrator).
On the part of the nurses, when they talk to patients, they need to explain it, sell it, but that takes time (Technologist).
The thing is, the staff in hospitals already seem to me to be up to their necks in work, so it’s like saying: give them training, explain once again that insomnia isn’t a false problem…my own perception of the healthcare system is that it’s clogged (Patient).
Considering the current lack of psychologists and that they all look overworked. Maybe they’ll also have difficulties. (Nurse).
As a psychologist who may end up with these patients, if we allow self-referrals, it’ll be chaos (Psychologist).
On the other hand, several stakeholders mentioned that the program may promote patients’ autonomy, could reduce the strain on resources and would fit well into routine care. Some also said that, while initially it might be perceived as contributing to their overload, the stepped care CBT-I could actually reduce it, at least for some providers, by providing a new service for an unmet need.
For us it might in some way reduce our workload because these people call us for these kinds of problems. The fact is it might already address the issue before it occurs (Nurse Navigator).
At first it might look a little like an extra burden, but after if it’s something that can help (Nurse Navigator).
Inside the treatment room, it’s when we see the patient’s set of side effects, it isn’t something you can easily find resources for (Nurse).
Maybe we’ll save time. Maybe there will be fewer demands on doctors, less strain on the pharmacy, maybe it will save time for other care providers (Technologist).
Remember that there is still many who won’t even need the booster sessions, the online modules will be enough for them (Psychologist).
Resistance to change. Resistance to change among cancer care providers was identified as an important potential barrier. Although inevitable, resistance to change was seen as surmountable. Changes are necessary to better address patients’ needs.
Whenever you have people involved, whether it be a department or young people or middle aged people or the elderly, there will always be resistance, so you just have to deal with it (Technologist).
Every kind of change brings [new] things. One is aware of that, probably it will work out just fine, everything will run smoothly. It’s a change and it’s a bonus for the patients (Nurse).
Process
Training. Cancer care providers mentioned that providing a brief training to all types of clinicians eventually involved would be a facilitator to its implementation. Ideally, cancer care providers should have the opportunity to become familiar with the website, the treatment content and the informational documents that will be distributed to patients beforehand.
It’s about making adequate training as brief as possible, covering the most important points. Yeah, then the information should be shared with everybody (Administrator).
What’s most important in terms of access is to make sure that the people who might be referring are really familiar with the platform (Social Worker).
There really has to be a meeting and they have to explain well, that’s how you bring it in and that’s the document that you give and we have to read that document ourselves before we hand it [to the patients] so that we can provide a minimum explanation (Technologist).
I think it’s a good tool, easy to use, if the nurses in the treatment room have been trained enough to know the contents so they can try to convince the patients to go there [on the website] (Nurse).
They [the booster sessions] are aimed at the needs that remain…for each patient. It’s in relation to what the patients have, the kind of problem they still have. So, that means that the professional who sees them has obviously been informed about CBT-I, has a clear idea what it is. (Psychologist).
Engaging. To be successful the implementation should also engage and rely on every professional working in oncology.
In addition, it shouldn’t just fall on the shoulders of two or three people but, but on everybody working in oncology (Administrator).
I think that for any kind of innovation, the people involved have to be participants in the process (Psychologist).
Motivation and commitment. The majority of health care providers interviewed expressed a strong desire to commit themselves to the implementation process and to propose the program to their patients.
My impression is that I would even prescribe it before medication, I wouldn’t even do both at the same time, I would have them begin with it and then see how it interacts (Technologist).
Personally, I’m sure that if they explain it to us, how to try to sell it, I’m sure I would be onboard 100% (Technologist).
Publicity. Participants also mentioned that, in order for the program to be sustainable, that the implementation team should generate a lot of publicity, not only at the beginning, but throughout the whole implementation process.
I think that it will need a lot of, in quotation marks, publicity…we’ll have to make sure everyone is on the same page (Hematologist-oncologist).
That goes for everything, whether it’s community resources, our services, they’ll publicize it all the time, all the time (Social Worker).