Focus Group Study of Heart Failure Nurses’ Perceptions of the Feasibility of Cognitive Behavioral Therapy for Insomnia

Abstract

Background:

People with heart failure (HF) often report insomnia with daytime consequences, including fatigue and decreased functional performance. Cognitive behavioral therapy for insomnia is an efficacious treatment, but few have access due to a shortage of trained sleep specialists. Access may be improved by offering it where people with HF receive care.

Objectives:

The purpose of this study was to explore the perceptions of nurses who specialize in HF regarding the value of cognitive behavioral therapy for insomnia to their patients, the feasibility of offering it in HF clinical settings, its delivery by nurses, and preferences for modes of delivery.

Methods:

We used a descriptive qualitative study design. We recruited focus group participants via email to American Association of Heart Failure Nurses members and through requests for nurse collaborators to distribute within their networks. We conducted focus groups via Zoom. After describing cognitive behavioral therapy for insomnia and its efficacy for people with HF, we elicited perceptions about its value if provided in the HF outpatient clinical setting, facilitators and barriers to implementation, and other ways to increase access. We audio-recorded and transcribed the discussions. Two researchers coded the data and performed thematic analysis.

Results:

Four focus groups included 23 registered nurses and advanced practice nurses employed in outpatient HF clinics. We identified five themes: “Insomnia Overlooked,” “Cognitive Behavioral Therapy for Insomnia Works,” “Nurses’ Role,” “Barriers and Supports,” and “Modes of Delivery.” Nurses endorsed the importance of insomnia to people with HF and the value of providing cognitive behavioral therapy. They expressed interest in evaluating and addressing sleep, the need for increased resources to address it, and multiple modes of delivery. All nurses believed they had a role in promoting sleep health but differed in their views about providing cognitive behavioral therapy for insomnia.

Discussion:

Nurses specializing in HF support the implementation of cognitive behavioral therapy for insomnia. Implementation studies are needed to identify effective methods to increase access to this efficacious treatment in outpatient HF clinical settings, including support and training for nurses who are interested and able to deliver it.

Chronic insomnia, “trouble initiating or maintaining sleep which is associated with daytime consequences and is not attributable to environmental circumstances or inadequate opportunity to sleep” (American Academy of Sleep Medicine, 2023), is prevalent among people with heart failure (HF; Redeker & Stein, 2006; Redeker et al., 2010). Comorbid insomnia confers a higher mortality risk (Seko et al., 2022), and insomnia is negatively associated with physical function, fatigue, depressive symptoms, daytime sleepiness, health-related quality of life, and adverse cardiac events (Redeker, 2010). Pharmacological treatments (Ulmer et al., 2017) lead to adverse daytime effects, and HF patients often prefer behavioral treatments (Andrews et al., 2013).

Cognitive behavioral therapy for insomnia (CBT–I), the first-line treatment for insomnia (Edinger et al., 2021), includes sleep hygiene education to address behavioral and environmental factors that affect sleep (e.g., avoiding caffeine, having a quiet space for sleep); sleep scheduling (e.g., establishing a consistent sleep/wake schedule); stimulus control (learning to associate the bedroom only with sleep); sleep restriction therapy (temporarily limiting time in bed to increase sleep efficiency); and cognitive restructuring (reframing negative thoughts and beliefs about sleep; Edinger et al., 2021). It may also include relaxation approaches, such as progressive muscle relaxation (Redeker et al., 2017). In a recent randomized controlled trial, CBT–I had sustained effects on insomnia, fatigue, excessive daytime sleepiness, and daytime function over 1 year among adults with stable HF (Redeker et al., 2022). However, despite CBT–I’s sustained efficacy and absence of side effects, it is underutilized (Koffel et al., 2020).

The lack of trained providers (Koffel et al., 2018) is a barrier to access. Although CBT–I is usually delivered by psychologists and others trained in psychotherapy, the demand for treatment has led researchers to explore CBT–I delivery by other providers. Nurses successfully delivered CBT–I in primary care settings in Sweden and the Netherlands (Sandlund et al., 2017; Siebmanns et al., 2020; Van der Zweerde et al., 2020) and provided brief behavioral treatment for insomnia in the U.S. (Dean et al., 2020). Nurses specializing in HF provide extensive support for self-management of HF symptoms; they may be well suited to support self-management intervention for insomnia, such as CBT–I, but little is known about the feasibility of providing CBT–I in outpatient HF clinical settings.

This focus group study aimed to explore the perceptions of nurses who specialize in HF care about the importance of insomnia, the value of CBT–I to their patients, and the feasibility and methods of delivering CBT–I by nurses in HF programs.

Methods

Design

The study included a qualitative descriptive design and was conducted from a northeastern U.S. setting. We obtained institutional review board approval and informed consent from participants. Participants received $25 for participating.

We recruited participants via email request to members of the American Association of Heart Failure Nurses and requests to nurse collaborators to distribute invitations through their clinical networks. Participants were English-speaking registered nurses practicing in outpatient HF clinics in the U.S. /We conducted focus groups on Zoom^™.

Procedures/Data Collection

Guided by Krueger and Casey (2015), we developed a semistructured focus group interview guide to elicit perceptions of the value of CBT–I for HF patients in the clinical setting, facilitators and barriers to implementation, and ways to increase access to CBT–I (see Table 1). We obtained input from a qualitative research expert and refined the interview guide accordingly. We collected demographic data with a brief questionnaire via email 2 weeks prior to the focus groups. Before beginning the group discussion, we provided a 15-min presentation with background information on the prevalence and consequences of insomnia in HF, the standard components of CBT–I (sleep hygiene, sleep scheduling, sleep restriction, stimulus control, cognitive restructuring), and information on the efficacy of 8-week CBT–I in HF identified in our recently completed randomized controlled trial (Redeker et al., 2022). In this study, CBT–I was delivered in four group sessions over an 8-week period, with telephone calls to participants on alternate weeks. We limited the discussion to 8-week CBT–I because of lack of evidence for the efficacy of abbreviated CBT–I interventions among people with HF. We allowed time for questions and confirmed that participants understood the components of CBT–I.

Table 1.

Presentation Content and Focus Group Interview Guide

Presentation Preceding Focus Group Discussion

Background on insomnia in people with HF and rationale for treatment with CBT-I

• Definition, prevalence and symptoms

Results from randomized controlled trial of 8-week CBT-I vs. 8-week HF self-management education (Redeker, et al., 2022)

In people with HF, CBT-I (vs. self-management) had sustained clinically significant effects on:

• Insomnia severity

• Sleep quality

• Sleep latency

• Sleep efficiency

• Fatigue

• Excessive daytime sleepiness

• Physical function

Components of 8-week CBT-I program (Redeker, et al., 2017)

• Four biweekly group sessions with check-in phone call with interventionist on alternate weeks

• Sleep Hygiene Strategies: consistent bed/wake times; sleep environment-dark, quiet, comfortable temperature; limit caffeine; avoid large meals, alcohol and exercise before bed; turn screens off at least 30 minutes before bed; avoid naps/short naps early in afternoon

• Sleep tracking & scheduling: sleep and wake up at about the same time every day; record schedule in sleep diary

• Calculate sleep efficiency; Aim is to increase sleep efficiency to 85%.

• Stimulus Control/Sleep Restriction: eliminate association between being in bed and being awake; get out of bed after 30 minutes if still awake, returning to bed when drowsy, but not more than 30 minutes. Repeat process as needed

• Cognitive restructuring: practice reframing negative thoughts about sleep; reduce attempts to control sleep

• Progressive Muscle Relaxation audio recordings

Focus Group Interview

Focus Group Interview Guide:

• What are your thoughts on the CBT-I program in general? About specific components?

• What are your thoughts about offering it in your setting? If not in your setting, where?

• How would you do it?

• What barriers, if any, do you foresee? Prompt: cost/insurance, space, time, provider familiarity, training providers, insurance payment

• What resources would be needed?

• How do you think it should be delivered? Prompt: group setting in-person, group setting Zoom, individual in-person, electronic delivery

• Who do you think should deliver it?

Note. HF= heart failure; CBT-I = cognitive behavioral therapy for insomnia

Two research team members with experience in qualitative interviewing and research conducted the interviews and took notes to aid the analysis. We audio-recorded and professionally transcribed interviews; a research team member read and validated each transcript, removing identifiers. We used Atlas ti ^™ for data management and analysis.

Data Analysis

We conducted inductive thematic analysis with methods described by Braun and Clarke (2006). Two researchers trained in qualitative research independently and jointly read the transcripts to gain familiarity with the data and developed a starter list of codes and subcodes derived from the text. We coded two transcripts and met to discuss discrepancies and agree upon a final code list. We coded each of the remaining transcripts independently and met to compare and discuss coding line by line for each transcript. Once all transcripts were coded, we analyzed the data by exploring patterns and identified potential themes and subthemes. We ensured trustworthiness of the data and analysis by returning to review transcripts for accuracy checks and ensure saturation of meaning (Hennick et al., 2017) and referred to field notes. We selected participant quotes to illustrate and help describe each theme.

Results

We enrolled 26 registered nurses; three dropped out due to scheduling conflicts. We conducted four focus groups over 2 months with 23 nurses who worked in outpatient HF clinics in nine states in the Northeast, Mid-Atlantic, Southeast, Midwest, and Western regions of the U.S. Most participants were White females and had been practicing for between 5–35 years (see Table 2). We identified five themes: “Insomnia Overlooked,” “CBT–I Works,” “Nurses’ Role,” “Barriers and Supports,” and “Multiple Modes of Delivery.”

Table 2.

Demographic Characteristics of the Sample (N=23)

Variable	N(%)	Mean (SD)
Age		48 (11.2)
Gender  Female	20(87%)
Male	3(13%)
Race  Black	3(13%)
White	20(87%)
Ethnicity  Not Hispanic	23(100%)
Education  Associate degree	1(4%)
Bachelor degree	10(44%)
Masters degree	7(30%)
Doctoral degree	5(22%)
Years in Practice		31(11.6)
Region of U.S.	11(48%)
Northeast	3(13%)
Mid Atlantic	2(9%)
Southeast	4(17%)
Midwest	3(13%)
West/Pacific Northwest

Insomnia Overlooked

All nurses reported that inadequate sleep is common among people with HF. They commented that insomnia may not be recognized because the health care team’s focus is on other causes of sleep disruption (e.g., sleep apnea, orthopnea, stimulant medications, nocturia, and leg cramps). Nurses commented, “You do hear a lot about sleep deprivation” and “sleep is often top of mind . . . they lead with that, ‘I had a horrible night last night’ . . .” but said insomnia is “something that I really don’t think about . . . I always think about the CHF [congestive heart failure] person having trouble sleeping because they can’t breathe because they’re building up fluid.” Others felt that health care providers focus on sleep apnea without considering other potential causes of sleep complaints, like insomnia: “It’s so overlooked, and we do blame it on apnea, ‘Go get your sleep study.’” Many nurses endorsed the need to “dig deeper,” saying, “If they say, I’m having trouble sleeping, well, is it because you can’t breathe when you lie flat? You have to find out more information. Sometimes it’s not; it’s not orthopnea at all.”

CBT–I Works

Several nurses believed that CBT–I would be beneficial for anyone with insomnia and were impressed to learn of its efficacy in HF and that it works “despite so many [HF] symptoms” known to disrupt sleep:

in that low EF (ejection fraction) population . . . getting them through in terms of cognitive restructuring somehow enabled them to relax enough so that shortness of breath wasn’t their deciding factor for inability to sleep. I think that’s really powerful.

Some nurses viewed CBT–I as a tool to make the best of a period of sleep that would inevitably be disrupted by HF symptoms:

. . . shortness of breath or just going to the bathroom in the middle of the night. Being able to help them to be able to use techniques to get them back to sleep quicker and stay asleep longer would certainly be very helpful.

Another nurse commented that if CBT–I could reduce fatigue, this would greatly benefit her patients. A nurse commented that the behavioral focus of CBT–I could increase motivation to address other sleep issues:

I think having a behavioral approach that they might be interested and just help them with the insomnia piece might help[ing] them be—and if they could see that it works, they may be more amenable to then trying CPAP again for their sleep apnea.

Nurses’ Role

Participants enthusiastically endorsed the idea that addressing sleep would fit within the scope of their work, given that self-management education is already a large part of their role: “We help patients live with whatever condition they have, and we try to help them integrate this into their life, not just treat their disease. I think it’s totally in line with what nursing is.” Many welcomed the challenge, saying, “I really think this is an opportunity for nurses, whether advanced-practice nurses or heart-failure nurses, to really shine.”

Evaluating Sleep

Many reported that they discuss sleep during every patient encounter in the context of evaluating symptoms of decompensated HF. Some nurses believed that evaluation of insomnia could be easily incorporated into regular visits and agreed they would like to address it, but some thought it would be at a “surface level . . . fairly basic level.” For example, one nurse said, “I’m wondering if just the simple question of, ‘does insomnia seem to be an issue for you?’” Some thought basic questions about sleep could be incorporated into regular phone calls made to HF patients in the weeks after hospital discharge. While some viewed sleep evaluation to identify sleep difficulties for referral to specialists, others thought a more in-depth sleep evaluation could be integrated into “multiple close follow-ups.” One nurse commented that some CBT–I components, including sleep hygiene, might be easily discussed during an HF visit: “[a patient says] ‘I go to bed, and I’m watching my cell phone, and I have Netflix playing in the background, and I can’t sleep,’ well, yeah, there’s a pretty targeted issue that you can address immediately…”

Nurses As CBT–I Interventionists

Many nurses expressed interest in delivering CBT–I and believed that other nurses would also be interested: “Most nurses are concerned about the patient’s well‑being as a whole, not just the medical side to it, and this falls into that other side that most nurses, I think, care about . . .” While many thought that “nurses in the clinic can easily be trained” to deliver “protocolized” CBT–I, others expressed concerns: “I don’t know that I’m personally equipped to manage that” and:

As far as administering a formal cognitive behavioral therapy program, I’m not sure as a family nurse practitioner that I’m licensed to do that . . . (need) either a psych NP [nurse practitioner] or a therapist or somebody who’s able to administer or work with a patient with cognitive behavioral therapy.

One suggested that CBT–I training could help meet nurse continuing education requirements.

Some expressed interest in delivering individual components of CBT–I, commenting, “There won’t be a one-size-fits-all approach,” “Which pieces . . . What things are they actually gonna do?” and “If we could separate some of the components . . . initiate a portion of it?” Regarding patients who may not need all CBT–I components, one nurse stated: “You also don’t wanna overwhelm them with the whole thing.” Nurses agreed that evaluating each patient’s specific sleep complaints could help target treatment: “Maybe the first clinic visit to figure out what is their major sleep problem and start with that component.”

Barriers and Supports

Time

Nurses identified several barriers to delivering CBT–I in the HF clinic. Most cited lack of time in the schedule to add something new: “The nurse practitioners are basically just go-go-go-go-go” and “From a provider standpoint, oftentimes we’re very overwhelmed with the sheer number of people that we have to see.” While many said they could envision using a sleep evaluation tool in the waiting room or doing brief sleep assessments by phone; all agreed that providing a comprehensive sleep intervention like CBT–I would require additional patient visits, as routine visits are 15–20 min and often feel too short “when you’re trying to see patients in the outpatient side and trying to get through their heart failure management, which is very difficult oftentimes and takes a lot of time, it’ll be difficult . . .” Some expressed concern about the frequency and intensity of visits needed to implement CBT–I in the clinic:

Cognitive behavioral therapy requires an ongoing conversation and relationship with a patient, so it’s not gonna be like you do a one-off administration . . . something much deeper than that, then I feel like it would be more beneficial to be able to refer to somebody who can see this patient more often.

Another nurse commented that she “wouldn’t wanna bring up topics like sleep hygiene and work with them about these topics, but then not be able to have the time to spend with the patients exploring how they can make those changes . . .” Due to time constraints, many felt the best option would be for patients to see providers with more time to address sleep but complained that there are few options for referral: There’s not a lot of options for therapists in our area” and “We don’t really have a lot of services to direct them to.” Some felt that therapists who use CBT should add CBT–I to their practice, “get this data into the hands of therapists or people that do CBT.”

Barrier: Costs to Patient

Several nurses expressed serious concern about their patients’ abilities to pay for CBT–I—even if it could be provided as part of their existing care—saying: “My patients cannot afford [the] copay. They can’t afford 5, 10, 15 . . .,” “Is there an add-on cost for this because most of the time there isn’t money to cover the copay of the HF clinic visit?” and “The patients pay the same copay whether they’re seeing me or a physician and for some, that really can be a hardship. The structure of the cost could also be something that could be, again, a barrier.”

Patient Factors

Nurses stressed that patient readiness to address sleep is important. Some HF patients are overwhelmed with other medical issues: “I think that they would be faced with so many other issues that they’re dealing with that I’m not sure where sleep would be on that hierarchy.” “They’re so overwhelmed after they see their provider . . . they just wanna go home ‘cause they’re exhausted. Their brains are overwhelmed.” Other patients have difficulty retaining information: “You have to reinforce every single time you see them . . . I do a lot of teach back . . . just to see if they even can remember what we talked about 15 min ago” and “When I call them after they’re discharged, I’ll start reminding them the things we discussed, and it’s interesting to see how many people really do remember and how many people go, ‘What am I supposed to do?’”

Nurses felt that some patients do not understand the significance of sleep and/or they are not motivated to address it: “Health literacy is pretty low” and “Perhaps many of the patients that I meet aren’t used to self-care . . . the actual concept of self-care is new to them.” Some patients may be hesitant to speak about sleep problems openly, which should be considered. Nurses commented, “If someone says no, it’s not something they’re interested in, there’s no point in giving it to them ‘cause they’re gonna be resistant to it” and “I have a lotta trouble getting patients to be interested in support-group options.”

A few nurses expressed frustration about patient adherence to recommendations and explained that “just getting them to show up” is challenging. Some commented that “I haven’t had good luck having patients’ complete diaries,” “That’s just another packet of information that they’re gonna ignore,” and “They tell you what you wanna hear when they’re there, but the reality is they have no intention of implementing it into their life. I know. That’s the struggle.”

When asked to consider the resources they would need to implement CBT–I if all practical barriers (cost, time, patient factors) could be overcome, nurses identified training, a model workflow, and buy-in from physicians.

Training

Nurses reported that training would be essential for learning the content of the program and increasing self-efficacy: “Feeling like we’re qualified to do this” and “Having people feel comfortable being able to do this intervention with all its associated parts—I think not just anybody’s gonna be able to just go and implement this.” Nurses would like to follow a “step-by-step” protocol or be provided with a “prescriptive unit, so to speak, that could be presented as a video . . . something along those lines, that would be very helpful.”

Model Workflow

Many expressed uncertainly about how a CBT–I program could be incorporated into their setting and asked for guidance: “From a workflow process, how you structure things . . . how does a clinic implement that . . .” and “I think that a session . . . with how to incorporate something like this into your practice, I think that that would be really, really wonderful.”

Support/Buy-In

All nurses agreed that for a CBT–I program to be successful in the clinic setting, several stakeholders would need to support it: “There has to be clinician buy-in, so the primary, the attending, the pulmonologist, the—it would be beyond helpful to have them invested in this idea that the patient’s sleep is meaningful and has been overlooked” and “The doctor side is what’s so important. So important.” Nurses shared ideas about gaining stakeholder support, including sharing research data. One nurse thought this would “help them [doctors] understand why this is important to do rather than say, ‘well, just take melatonin or just get over yourself and don’t worry about that, we’ve got other things to worry about.’” Another commented, “. . . I think showing the benefit . . . is ultimately where it needs to go.” Many felt that increasing provider awareness of the prevalence of insomnia in their patients would motivate them to support the use of CBT–I:

Identifying a large group of our patients who have this problem and are looking for help with . . . they really do care about their patients . . . that would be the number one reason why they would be open to it.

Another noted that sharing research data showing that CBT–I can improve fatigue and function in people with HF would increase provider interest.

Multiple Modes of Delivery

Nurses believed that there are several good options for delivering CBT–I to HF patients and shared that it will be valuable to provide choices and to make it easy for patients to participate. Nurses recommended taking advantage of existing means of communicating with patients, naming educational TV in the clinic waiting room as an example: “It doesn’t cost us anything. It’s just a video that goes on our education channel.” Nurses endorsed a range of delivery options, including telephone, telehealth, apps, and online and in-person group meetings.

Nurses recommended that if CBT–I were provided to patients by an outside specialist or ancillary service, there should be coordination with the cardiology practice: “Specifically for HF patients because if there has to be some medication changes” and “I would think cardiology would have to be involved at some point with oversight.” Similarly, while many nurses believed they could be trained to implement CBT–I, they felt it could be delivered by other providers in or associated with the clinic, including social workers, lifestyle management physician associates, and “our sleep partners in pulmonary.” One nurse commented: “We refer almost all our patients for a sleep study. Is this something that can be done in conjunction with that?”

Others recommended licensed therapists or “a psych NP,” community health workers, and home care nurses. One nurse thought that a “lay person” could be trained to deliver CBT–I, while another said: “It might even be a peer sleep coach . . . it could be a can [certified nursing assistant].” One nurse suggested that CBT–I could be incorporated into home visits: “We actually go into the home . . . during each touchpoint, we can reinforce those techniques and reinforce those things that would help improve their sleep.” Others agreed, saying. It’s like having an old-fashioned doctor’s visit when they used to come to the home” and “the home setting might be a little bit nicer for them.”

Cardiac Rehabilitation

Several nurses recommended embedding CBT–I in existing cardiac rehabilitation programs, given the support and frequency and structure of those visits: “I think cardiac rehab has shown us over the years that what keeps people going is that camaraderie, that support, the frequency of those visits, and that they support and care about one another.” One nurse noted, “Psychologists are part of our cardiac rehab program, and they are available for intervention.” While all agreed that cardiac rehab programs may be ideal, they acknowledge that not all HF patients are referred: “Not everybody participates in cardiac rehab.”

Phone Calls

Some nurses favored the telephone for sleep inquiries: “There is a phone call after discharge that goes out to every CHF patient . . . I’m wondering if just the simple question of, does insomnia seem to be an issue for you . . .” and “On our heart failure calls, if they have insomnia issues, and we could make a list of patients that may be interested.” Some nurses felt that the phone could be used to deliver components of CBT–I in a prerecorded audio message because “they certainly know how to use phones . . . but they may not be great with technology.”

Telehealth

While all nurses acknowledged that patients were often resistant to or had difficulty using technology, they felt that many overcame related challenges during the COVID-19 pandemic and telehealth is a viable option for CBT-I delivery:

. . . I think with COVID and the fact that we’re doing so many telemedicine visits, especially with our heart failure patients to keep them out of the hospital . . . patients have found a way to access technology.

Apps

Nurses recommended that apps be used to deliver CBT–I, but only for a select group of patients who already use them: “For those who use them . . . sometimes older people don’t use apps. They’re not comfortable with apps. It stresses them out more.” Some nurses considered apps and other electronic methods of delivery to be good for introducing CBT–I:

AI programs are becoming more and more advanced, like you go on Amazon to talk to the help desk or whatever, and . . . you’re talking to an algorithm. What I wonder is if . . . an algorithm could be utilized so that . . . the CBT–I was being administered through an algorithm at a basic level.

Group Intervention

Nurses had some experience with providing online education to patients and recommended CBT–I delivery to groups online: “We had a fairly robust response to our virtual education classes” and “It’s just the group of heart-failure patients discussing what they’ve done to benefit or what doesn’t benefit and have an open discussion about it.” Others favored in-person groups, saying, “I think having a structured place for patients to talk about their sleep and seeing what other folks are doing, that’s beneficial to them . . . there’s a social piece . . .”

Discussion

CBT–I is the gold-standard treatment for insomnia, and it is efficacious and safe for people with HF (Redeker et al., 2022). However, it will be underutilized until the shortage of providers is addressed, or additional delivery methods become widely available. To our knowledge, this is the first published qualitative study to explore the feasibility of engaging outpatient nurses specializing in HF care in implementing CBT–I.

Nurses recognized the importance of insomnia for their patients and supported the implementation of CBT–I in HF clinics. However, they highlighted a critical barrier to implementing CBT–I: insomnia is overlooked, partly due to a provider focus on sleep apnea. Over half of the people with HF have sleep-disordered breathing (Pearse & Cowie, 2016), and insomnia affects approximately 50% (Redeker et al., 2010). The association between sleep disordered breathing and HF is well documented (Yancy et al., 2017), and HF providers often refer patients for sleep studies. It is less well-known that insomnia and sleep apnea are distinct but overlapping disorders that both require treatment (Ragnoli et al., 2021). “COMISA,” or Co-Morbid Insomnia and Sleep Apnea, can result in more severe illness, and each can impede treatment of the other condition (Ragnoli et al., 2021). Treating insomnia improves adherence to CPAP (Sweetman et al., 2022). Indeed, nurses felt that patients who had difficulty using CPAP might try again if insomnia were addressed. There is also a need to raise awareness among health care providers who treat people with HF about the prevalence and significance of insomnia separate from sleep apnea and the efficacy of CBT–I. Overcoming these barriers will be critical to generating physician “buy-in” which nurses feel is critical to implementing CBT–I.

All participants agreed that nurses are well-positioned to support people with HF in addressing their sleep. They viewed it within the scope of their health education work, aligning with their “holistic view” of health. Others have suggested that nurses are ideal candidates to deliver behavioral sleep interventions and are an underutilized resource (Fields et al., 2013). With a 4:1 ratio of nurses to physicians in the U.S. (Organisation for Economic Co-operation and Development, 2017), nurses comprise the largest segment of health care providers (Laughlin et al., 2021). Notably, all nurses in this study expressed interest in delivering CBT–I if barriers (time, cost) could be overcome; however, some questioned whether they were qualified and whether it should be left to mental health professionals. However, there is evidence that nurses are effective CBT–I interventionists in the primary care setting. Baccalaureate and master’s prepared nurses have successfully implemented manualized behavioral treatments in research studies in primary care, with positive changes in sleep characteristics (Bothelius et al., 2013; Sandlund et al., 2017). With training, it is likely that nurses who specialize in HF could also effectively implement protocolized CBT–I.

CBT–I is safe and efficacious in many groups; our recent trial demonstrated this among people with HF (Redeker et al., 2022). Potential minor side effects include daytime sleepiness associated with sleep restriction. We addressed this in our study by excluding participants who had excessive daytime sleepiness and tailoring sleep restriction to avoid unsafe levels of sleepiness. We also excluded participants with severe depression. Possible side effects were not reported in our trial, and there were no reportable adverse events, in contrast to some prescribed and over-the-counter medications that induce negative daytime effects. Nevertheless, these precautions should be observed when implementing CBT–I in clinical practice.

Prior studies suggest that the time and costs of implementing CBT–I are significant barriers to providing it in clinical settings (Haynes et al., 2018). Nurses strongly recommended that multiple modes of delivery—including self-directed phone-based applications or interventionist-based telephone calls—could be used to meet the demand for CBT–I. Emerging research suggests that digital CBT–I is noninferior to face-to-face, therapist-led interventions (Gao et al., 2022). However, to our knowledge, it has not previously been tested in this population, nor have brief CBT–I interventions. Nurses recommended offering only components of CBT–I that address patients’ symptoms to reduce patient burden and time costs. Research will be needed to determine the feasibility and efficacy of assigning specific components of CBT–I to HF patients based on their sleep symptoms. Another possibility is implementing a stepped-care delivery model, as proposed by Espie (2009), whereby participants receive one of five levels of CBT–I started with the least intensive and increased in “steps” based on need when first level of care is insufficient. Interventions targeted to the severity of insomnia or insomnia refractory to initial intervention may also be useful (Manber et al., 2014; Savard et al., 2022), cost-effective, and favored by participants (Koffel et al., 2021). While these approaches are under investigation (Manber et al., 2022; Spiegelhalder et al., 2022), to our knowledge, no studies have addressed these approaches among adults with chronic HF. Given the high prevalence and negative consequences of insomnia in this population, these questions warrant further study.

Strengths and Limitations

Strengths of the study include rigorous qualitative methods, including a team-based approach with multiple researchers participating in data collection, coding, and analysis. Inclusion of nurses who specialize in nursing care for people with HF from several regions of the U.S. and with varying levels of education and experience provided diverse perspectives. However, the convenience sample may have been biased, with a high proportion of nurses with special interests in sleep. Further, nurses were presented with information about the components of CBT–I and its efficacy as a treatment for insomnia among people with HF, but their lack of firsthand observation of or participation in CBT–I may have limited their ability to assess the feasibility of implementation in the clinic setting.

Conclusion

CBT–I implementation studies are needed to increase access to evidence-based CBT–I for people with HF in the HF clinic setting. These studies should address the need for appropriate support and training for nurses interested in its delivery. Research to identify feasible and acceptable CBT–I delivery methods beyond the traditional clinic setting is also needed and will expand the reach, effectiveness, implementation, and long-term maintenance of this efficacious treatment for people with HF.