Behavioral Sleep Medicine, 13:36–51, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1540-2002 print/1540-2010 online DOI: 10.1080/15402002.2013.838766

Barriers and Facilitators of Evidence-Based Practice in Pediatric Behavioral Sleep Care: Qualitative Analysis of the Perspectives of Health Professionals Katelynn E. Boerner and J. Aimée Coulombe Department of Psychology and Neuroscience Dalhousie University

Penny Corkum Departments of Psychology and Neuroscience, Pediatrics, and Psychiatry Dalhousie University; IWK Health Center, Halifax; and ADHD Clinic Colchester Regional Hospital, Halifax

Behavioral sleep problems are highly prevalent among young and school-aged children. Despite strong evidence for effective interventions, few children receive evidence-based care. In this study, 124 Canadian health professionals answered open-ended questions regarding barriers and facilitators of their provision of evidence-based behavioral sleep-related care, and responses were analyzed for content. Responses represented issues at an individual practice level, as well as broader systemic issues. The most frequently reported barrier and facilitator related to knowledge, training, and education. Other barriers included lack of time and institutional support, and facilitators included supportive sleep attitudes and beliefs. This study may inform the design of education programs for health professionals, and provides support for broader systems-level initiatives targeted at increasing evidence-based practice.

Sleep problems attributable primarily to behavioral factors are highly prevalent, being experienced by approximately 30% of children between the ages of 1 and 10 years old (Bruni et al., 2004; Owens, 2008). Adequate sleep is essential for health, and is of particular importance in childhood, as children undergo periods of rapid development with sleep necessary for the function of numerous physical systems (Hill, 2011). Children who are receiving inadequate Correspondence should be addressed to Penny Corkum, Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford St., P.O. Box 15000, Halifax, Nova Scotia, Canada B3H 4R2. E-mail: [email protected]

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sleep are at risk for physical, cognitive, emotional, and academic difficulties, and the negative effects of behavioral sleep problems may be felt by the entire family (Gregory & O’Connor, 2002; Hill, 2011; Owens, 2008). Research in school-age children has shown profound effects on functioning after a very modest restriction of sleep, highlighting the importance of identifying and treating children who are not receiving adequate sleep on account of behavioral sleep problems (Sadeh, Gruber, & Raviv, 2003). Brief behavioral interventions have been established as effective treatment for Behavioral Insomnias of Childhood (BICs; Hill, 2011; Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). Unfortunately, little is known about how best to increase access to evidence-based sleep-related care for children and their families. Clearly there are not enough behavioral and pediatric sleep specialists to provide services to the large population of children with BICs (Owens & Mindell, 2006). However, many children with behavioral sleep problems do not require specialized services and could be treated in a primary care setting or by health professionals already involved in a child’s health or mental health care (i.e., non-sleep specialist health professionals; Bhargava, 2011). Unfortunately, the fact that few health and mental health professionals currently possess sufficient training in sleep limits the feasibility of this solution (Bruni et al., 2004; Meltzer, Phillips, & Mindell, 2009; Mindell, Moline, Zendell, Brown, & Fry, 1994). Additionally, other potential barriers and facilitators of pediatric sleep-related care amongst health professionals are less well understood. Previous research has found a significant lack of sleep-related knowledge in health professionals that encounter sleep problems, and that in the absence of sufficient education health professionals may rely on common beliefs, rather than evidence-based information, in making their decisions regarding children’s sleep (Bruni et al., 2004; Owens, 2001). Early studies of pediatrician training indicated a distinct lack of education in sleep, with one study reporting the median and mode duration of instruction in sleep being zero hours in pediatric residency programs (Mindell et al., 1994; Rosen, Rosekind, Rosevear, Cole, & Dement, 1993). Despite the fact that a lack of training in sleep was identified as an issue close to 20 years ago, little appears to have changed with regard to increasing the quality or quantity of sleep education received by health professionals in recent years (Mindell et al., 2011; Rosen & Zozula, 2000). While Canada currently appears to have more sleep education included in their medical school curricula than other countries, there still appears to be a significant lack of education provided, particularly in the area of pediatric sleep (Mindell et al., 2011). With regards to training of psychologists, a recent study found that training on sleep in clinical psychology programs was rare, and it was hypothesized that the barriers to the education of clinical psychology trainees were the lack of expertise among faculty members, cost, and the lack of time for training (Meltzer et al., 2009). Gruber, Cassoff, and Knauper (2011) suggested that in addition to lack of knowledge about the impact of sleep problems in children, health professionals also lack time; sleep must compete with numerous additional demands on the time of primary care pediatricians. Despite there being a strong rationale for speculating that these factors provide barriers to behavioral sleep-related care, to date there has been no empirical investigation of health professionals’ perspectives on the barriers and facilitators they experience in the provision of evidence-based sleep care. Such questions must be addressed if pediatric health professionals are expected to incorporate the provision of sleep-related services into their existing practices, and for researchers, educators, and policymakers to understand what role they can play in facilitating this care.

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The objective of this study was to identify behavioral sleep-related service barriers and facilitators experienced by Canadian non-sleep specialist health professionals (physicians, nurses, psychologists, and social workers) who regularly work with physically healthy1 children aged 1 to 10 years. It was expected that barriers to providing BIC-related services may include lack of training, time, and resources (Gruber et al., 2011; Meltzer et al., 2009), and that facilitators of providing BIC-related services may include training, resources, and specialist support. This study sought to identify other barriers and facilitators of evidence-based BIC-related practice (e.g., beliefs and attitudes), beyond BIC-related knowledge, that might also influence access to sleep-related care, as provided by non-sleep specialists. This would be a novel and significant contribution to the pediatric sleep field and could be applied to increase the effectiveness of knowledge translation efforts and inform the development of stepped care models for pediatric sleep.

METHOD Participants Potential participants were recruited to participate in this study through e-mails, letters, phone calls, newsletters, word-of-mouth, listservs, and alert systems through professional bodies and organizations. Health professionals were eligible to participate if they were (a) a credentialed, independent practitioner in one of the identified health and mental health professional groups (physician, nurse, psychologist, social worker) for at least 6 months prior to recruitment, (b) currently practicing in Canada, (c) seeing generally health 1- to 10-year-old children as part of their practice, and (d) able to complete online questionnaires in English. These health professional groups were selected for inclusion in this study as they regularly encounter children with sleep problems in their daily practice, and can either address these problems directly or refer for additional services. These groups are also often the audience of clinically focused reviews encouraging health professionals who already work with children to include sleep in their practice (Gruber et al., 2011; Moore, 2012; Piccione & Barth, 1983). Procedure Data presented in this manuscript is taken from a larger questionnaire-based study examining the feasibility of increasing access to evidence-based behavioral sleep-related care by supporting non-sleep specialist health professionals’ ability to provide these services. Specifically, the larger study examines sleep-related knowledge, attitudes, and beliefs as predictors of sleeprelated practice, and identifying where health professionals’ current knowledge comes from. As a sufficient sample size had been collected to proceed with qualitative analysis of the open-ended questions—that is, analysis of the responses to these questions revealed saturated themes—it was deemed appropriate to commence analysis of this section of the study prior to the completion of the larger study. The results of this larger study will be presented in separate 1 Sleep problems attributable to or comorbid with medical conditions may require a more specialized skill set and, thus, were not the focus of this work.

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publications. Data for the larger study was collected as an online survey using Opinio software. Potential participants received study information either directly (e.g., via e-mail after having been identified through publicly available professional listings) or indirectly (e.g., through emails circulated through university and hospital departments) and were provided with a link to the survey. After providing consent, participants were presented with a series of online questionnaires. Once participants completed the study questionnaires, they were thanked and provided with the option to be entered into a draw for one of four gift cards. The larger study was approved by the IWK Health Center research ethics board (Halifax, Nova Scotia, Canada).

Measures Demographics. This investigator-created questionnaire consisted of 10 items asking about participants’ profession, sex, Canadian province in which they practice, practice setting, and training in sleep, behavioral sleep problems, and behavior change. Items from this questionnaire have been adapted from measures used previously by Meltzer et al. (2009), Owens et al. (2011), and Papp et al. (2002). These questions were used to describe the participant sample, as well as their training specific to behavioral sleep issues. Readiness for Change Questionnaire. The Readiness for Change Questionnaire is a three-item questionnaire adapted from a measure used by Corkum and colleagues (Elik, Corkum, McGrath, & Kutcher, 2009–2012), based on the Stages of Change Model (Prochaska & DiClemente, 1985). The first item measured the participants’ readiness to learn more about BICs, asking participants to select which of four statements relating to their willingness to learn more about behavioral sleep problems they most strongly identify with. This was followed by two open-ended questions designed to elicit barriers to and facilitators of BIC-related practice, presented as follows: “If you do not provide behavioral sleep-related care, or are not able to provide the level of behavioral sleep-related care that you would like to, what are the barriers you experience?”; and “If you are able to provide the level of behavioral sleep-related care that you would like to, what has facilitated this?”

Analysis Responses to the open-ended questions were broken down into units of analysis; a unit of analysis was defined as the expression of a single idea. For example, the response “sleeprelated training in grad school, consultation with colleagues” would contain two units of analysis: (a) “sleep-related training in grad school” and (b) “consultation with colleagues.” This was done individually by two of the authors (Katelynn E. Boerner and J. Aimée Coulombe), who then compared their units of analysis and resolved any discrepancies through discussion. Development of the coding scheme occurred through an iterative process of examining the content of the units of analysis and discussion between two of the authors (Katelynn E. Boerner and J. Aimée Coulombe; consistent with conventional content analysis; Hseih & Shannon, 2005). The final coding scheme with definitions of each code is included (see Appendices 1 and 2) and was used by both authors to independently code each unit of analysis. Percentage of agreement between coders was excellent at 91.2% for the barriers and 95.7% for the facilitators.

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Descriptive quantitative analyses (e.g., frequency with which each barrier/facilitator unit of analysis was reported) were conducted. It is important to note that, as participants could identify multiple barriers and facilitators, there were more units of analysis than participants. Results indicate the frequency with which each unit of analysis was reported.

RESULTS Demographics Demographic characteristics are reported only for those participants that provided an answer to one or both of the open-ended questions. Out of 230 individuals who consented to participate in the larger study, 124 participants answered the barriers or facilitators open-ended question. There were no significant differences on any of the demographic variables between the individuals who did and did not answer the barriers or facilitators questions. Sixty participants provided responses to the barriers question only, 42 participants provided responses to the facilitators question only, and 22 participants provided responses to both questions. The demographic information that follows describes only those individuals that responded to the barriers or facilitators questions. Participants were predominantly female (n D 108; 87.1%). There was at least one participant from each of the 10 Canadian provinces; there were no participants from any of the three territories. Participants represented four health professional groups: physicians (n D 38; 30.6%), nurses (n D 23; 18.5%), psychologists (n D 43; 34.7%), and social workers (n D 20; 16.1%). Health professionals had an average of 14.85 years (SD D 9:86, range D 1–41 years) experience working professionally with children aged 1 to 10 years, and spent an average of 43.9% (SD D 29:2%, range D 2%–100%) of their time working with generally healthy 1to 10-year-old children in a clinical capacity. Of note, participants who responded to the barriers question only (M D 11:58 years, SD D 9:45) had significantly less experience working professionally with children aged 1 to 10 years than participants who responded to the facilitators question only (M D 17:69 years, SD D 9:18) and participants who responded to both questions (M D 18:36 years, SD D 9:75), F .2; 121/ D 7:064, p D :001. The most common clinical setting that participants practiced in was private practice (n D 43; 34.7%), followed by community health or mental health centers (n D 36; 28.2%), and hospitals (n D 33; 26.6%). A minority of participants reported working in “other” settings (n D 4; 3.2%; e.g., public health office), schools (n D 2; 1.6%), primary practice settings based out of universities (n D 2; 1.6%), and four participants did not indicate their primary practice setting. Regarding sleep-related practice, 93.5% of participants .n D 116/ reported addressing sleep in some clinical capacity in the setting in which they worked, which included services such as consultation, screening for sleep problems, answering parent questions about sleep, providing sleep education, suggesting resources, and providing treatment for sleep problems. Approximately 31.2% of participants reported that less than 20% of the 1- to 10-year-old children in their clinical setting have behavioral sleep problems, 39.3% of participants reported that 20% to 40% of children in their clinical setting have behavioral sleep problems, 19.4% of participants reported that 40% to 60% of children in their clinical setting have behavioral sleep problems, and 8.16% reported that greater than 60% of children in their clinical setting

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have behavioral sleep problems. Note that participants were asked to estimate the number of children with behavioral sleep problems, which may not be indicative of the number of children that actually receive screening, assessment, or treatment for their sleep problems. When asked to indicate which sources of information or training participants had used to obtain their knowledge regarding behavioral sleep problems in children, they endorsed: peer-reviewed journals/practice guidelines/textbooks (n D 81; 65.3%), Web resources for professionals (n D 45; 36.3%), lectures or grand rounds (n D 52; 41.9%), workshops or coursework (n D 42; 33.9%), clinical placements as a trainee (n D 30; 24.2%), research involvement (n D 5; 4%), and consultation with colleagues (n D 69; 55.6%). Participants could indicate obtaining sleep-related knowledge from more than one source. Nine participants (7.3%) indicated that they had no exposure or training on this topic. Planned Changes to Sleep-Related Practice The majority of participants indicated that they either have been learning about behavioral sleep problems for a long time and wish to continue their education (n D 47; 37.9%) or that they believe that they should learn more about behavioral sleep problems (n D 54; 43.5%). Additionally, a smaller group of participants reported having begun to learn more about behavioral sleep problems, and saw this as beginning to help improve their clinical practice (n D 23; 18.5%). None of the participants identified with the statement, “I do not believe that learning new information about behavioral sleep problems will change my clinical practice.” Of note, there appeared to be differences in planned changes to sleep-related practice between participants who answered the barriers question only, the facilitators question only, and those who answered both (see Table 1; F D 19:53, p D :000). Participants who responded to the facilitators question only appeared to be farther along in their planned changes to sleep-related practice than those who responded to the barriers question only. TABLE 1 Number (Percentage of Total) of Participants in Each Category of Planned Changes in Sleep-Related Practice, Divided by Whether They Answered the Barriers Question Only, Facilitators Question Only, or Both Questions Variable Open-ended question(s) participants responded to

Barriers only (n D 60) Facilitators only (n D 42) Both (n D 22)

Response to Planned Changes in the Sleep-Related Practice Question “For a long time, I have been learning about behavioral sleep problems, and I would like to continue to learn and remain up to date on this topic” 14 (23.3%) 26 (61.9%) 7 (31.8%)

“I have started to learn more about behavioral sleep problems, and see that it is beginning to help me improve my clinical practice” 10 (16.7%) 6 (14.3%) 7 (31.8%)

“I think I should learn some more about behavioral sleep problems, as it may help me to improve my clinical practice” 36 (60.0%) 10 (23.8%) 8 (36.4%)

Note. Fisher’s exact test revealed significant differences in response options, F D 19:53, p D :000. Examination of the standardized residuals indicated that, among participants who responded to the facilitators question, there were more who responded, “For a long time : : : ,” than would be expected.

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Barriers One hundred forty-seven units of analysis (i.e., individual barriers) were identified in responses from 82 participants who completed the open-ended question regarding barriers to practice. The range of units of analysis provided by each participant was 1 to 4, with 46.3% of participants providing only one unit of analysis, 32.9% of participants providing two units of analysis, and 20.7% of participant providing three or four units of analysis. Overall results across health professional groups are reported below, and the frequency with which each barrier was reported between different health professional groups is provided in Table 2. Barriers to the provision of evidence-based behavioral sleep-related care were as follows, listed from most to least commonly reported: lack of knowledge, skills, techniques, training, education (identified 44 times, 29.9% of total units of analysis); lack of time (identified 24 times, 16.3% of total units of analysis); institutional/systems-level/practice setting barriers (e.g., patients with sleep problems not seen in this setting, constraints relating to a specific practice setting, lack of opportunities to consult, lack of funding/support from management; identified 22 times, 15.0% of total units of analysis); barriers related to individual practice and professional orientation (e.g., sleep not identified as a priority by the health professional, sleep problems seen as outside of the scope of their practice; identified 18 times, 12.2% of total units of analysis); lack of resources and materials (identified 15 times, 10.2% of total units of analysis); barriers related to parents or a mismatch between parent and health provider or setting (e.g., parent expectations, parent resistance, cultural differences between parent and health provider; identified 15 times, 10.2% of total units of analysis); lack of access to sleep specialists or sleep services (identified 4 times, 2.7% of total units of analysis); other (identified 4 times, 2.7%

TABLE 2 Number (Percentage of Total Who Responded to the Barriers Question) of Health Professionals in Each Group That Reported at Least One Barrier in Each Category

Barrier Lack of knowledge, skills, techniques, training, or education Lack of resources and materials Lack of time Institutional/systems-level/practicesetting barriers Lack of access to sleep specialists/sleep services Barriers related to parents, mismatch between parent and health provider or setting Barriers related to individual practice and professional orientation Lack of experience Other

Physicians (n D 31)

Psychologists (n D 22)

Nurses (n D 16)

Social Workers (n D 13)

10 (32.3%)

10 (45.5%)

13 (81.3%)

4 (30.8%)

6 (19.4%) 16 (51.6%) 8 (25.8%)

6 (27.3%) 5 (22.7%) 5 (22.7%)

1 (6.3%) 3 (18.8%) 2 (12.5%)

1 (7.7%) — 4 (30.8%)

4 (12.9%)

—

—

—

4 (12.9%)

2 (9.1%)

—

5 (38.5%)

7 (22.6%)

6 (27.3%)

2 (12.5%)

2 (15.4%)

— 2 (6.5%)

— 1 (4.5%)

1 (6.3%) —

— 1 (7.7%)

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of total units of analysis); and lack of experience (identified 1 time, 0.7% of total units of analysis). Facilitators One hundred forty units of analysis (i.e., individual facilitators) were identified in responses from 64 participants who completed the open-ended question regarding facilitators to practice. The range of units of analysis provided by each participant was 1 to 8, with 45.3% of participants providing only one unit of analysis, 26.6% of participants providing two units of analysis, 12.5% of participants providing three units of analysis, and 15.6% of participants providing four or more units of analysis. Overall results across health professional groups are reported below, and the frequency with which each facilitator was reported between different health professional groups is provided in Table 3. Facilitators to the provision of evidence-based behavioral sleep-related care were as follows, listed from most to least commonly reported: knowledge, skills, techniques, training, education (identified 51 times, 36.4% of total units of analysis); institutional/systems-level/practice setting facilitators (e.g., opportunities for consultation, support from management, systems-wide beliefs and practices, practicing in a specific setting; identified 24 times, 17.1% of total units of analysis); experience (identified 19 times, 13.6% of total units of analysis); facilitators related to individual practice and professional orientation (e.g., health professionals’ commitment to sleep, belief in the value of sleep, being genuine and supportive with parents; identified 17 times, 12.1% of total units of analysis); resources and materials (identified 12 times, 8.6% of total units of analysis); facilitators related to parents (e.g., parent willingness, relationship with family; identified 7 times, 5.0% of total units of analysis); access to sleep specialists or sleep services (identified 5 times, 3.6% of total units of analysis); time (identified 3 times, 2.1% of total units of analysis); and other (identified 2 times, 1.4% of total units of analysis). TABLE 3 Number (Percentage of Total Who Responded to the Facilitators Question) of Health Professionals in Each Group That Reported at Least One Facilitator in Each Category

Facilitator Knowledge, skills, techniques, training, or education Resources and materials Time Institutional/systems-level/practice-setting facilitators Access to sleep specialists/sleep services Facilitators related to parents Facilitators related to individual practice and professional orientation Experience Other

Physicians (n D 31)

Psychologists (n D 22)

Nurses (n D 16)

Social Workers (n D 13)

8 (61.5%)

12 (44.4%)

5 (55.6%)

7 (46.7%)

1 (7.7%) — 1 (7.7%)

5 (18.5%) 1 (3.7%) 9 (33.3%)

2 (22.2%) 1 (11.1%) 4 (44.4%)

3 (20.0%) 1 (6.7%) 6 (40.0%)

1 (7.7%) 1 (7.7%) 3 (23.1%)

2 (7.4%) 1 (3.7%) 5 (18.5%)

— — —

1 (6.7%) 4 (26.7%) 4 (26.7%)

4 (30.8%) —

7 (25.9%) 1 (3.7%)

— —

3 (20.0%) 1 (6.7%)

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DISCUSSION This study investigated the barriers and facilitators to the provision of evidence-based behavioral sleep-related care by Canadian non-sleep specialist health professionals. A number of barriers and facilitators were reported, representing a diverse sample of experiences from individuals working in a variety of health care settings. Barriers and facilitators represented issues at an individual practice level, as well as broader systemic issues. By far, the most commonly reported barrier related to a lack of knowledge, specific skills or techniques, and education/training. This is supported by the small number of participants who endorsed clinical placements as a source of training or knowledge related to behavioral sleep problems in children, and the almost 10% of participants who endorsed having no exposure or training in this area. Interestingly, this finding was complementary to the facilitators, in which this category was the most highly endorsed as facilitating evidence-based behavioral sleep-related care. While some health professionals reported their professional education as facilitating their practice, the majority of individuals reported that their knowledge was gained through continuing education and self-directed learning. This is concordant with previously reviewed literature demonstrating that formal education in sleep is lacking in health professional training programs (Meltzer et al., 2009; Mindell et al., 2011; Rosen & Zozula, 2000). A recent study of training in sleep in psychology programs suggested numerous negative outcomes associated with a lack of training in sleep, including unnecessary or inappropriate referrals to specialists, inappropriate interventions being delivered, non-evidence-based practice, or a lack of attention to sleep symptoms at all (Peachey & Zelman, 2012). Issues such as inappropriate referrals to sleep specialists may have large impacts on wait-list times for families, as well as excessive costs to the family or the health care system (Owens, Kothare, & Sheldon, 2012). The lack of knowledge, skills, techniques, education, and training appeared to be particularly salient for nurses, with 81.3% of those who answered the barriers question indicating at least one barrier related to this issue. There is clearly a need to better understand how to facilitate education amongst health professionals to ensure that high-quality patient care is being provided. Time was the second most commonly reported barrier to pediatric sleep practice, both in terms of time within sessions to provide sleep-related services, time for follow-up appointments with families, and also in terms of time for training and continuing education. In particular, over one-half of physicians who responded to the barriers question indicated issues relating to a lack of time. Feasible models of education and sleep service delivery that include non-sleep specialist health professionals will need to address this barrier. Interestingly, while a lack of time was the second most commonly reported barrier to pediatric sleep practice, time was only listed in 2% of the facilitators identified. While it is certainly the case that health professionals have many demands on their time in both training and practice, it appears that time is not seen as a particularly critical facilitator to health professionals who are providing evidence-based care. Perhaps it is the case that these individuals have found methods by which to successfully integrate sleep-related care into their current practice, such that it does not require unreasonable amounts of additional time spent in assessment, treatment, and training. It is also possible that for these individuals, many of whom identified their own practice orientation/philosophy as having strong views regarding the importance of sleep, overcoming obstacles such as time is seen as less of a barrier because of their firm belief in its importance. Greater understanding

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of how individuals and institutions organize their time to facilitate sleep-related services is required. Of note, the second most commonly reported facilitator to the provision of pediatric behavioral sleep care related to institutional practices, highlighting the need for institutional support and potentially practice changes on a systemic level. This is consistent with Espie’s (2009) assertion that the organization and provision of insomnia care needs to be addressed at a health systems-level, for example, through a stepped care model in which sleep-related care is provided at multiple levels of specialization and intervention. In such a model, the most common and least complex behavioral sleep problems would be treated using widely accessible self-administered evidence-based interventions (e.g., booklet, Web sites). Referral to sleep specialists, who often have extensive waitlists and require families to travel to large urban centers for access to services, would be reserved exclusively for children who truly require specialized care. Intermediate levels of care are currently less well defined, particularly in regard to pediatric (vs. adult) sleep services, but would likely consist of group and individual interventions delivered by non-sleep specialists already involved with children’s care (Corkum, Godbout, Hall, Reid, & Coulombe, 2012). This role, however, requires adequate training in sleep and sleep interventions and a willingness and capacity to provide these services. Properly trained and resourced, these individuals, who are the focus of this study, could also act as effective gate-keepers for other levels of care (i.e., directing families to selfadministered or specialized services). This is of particular importance in Canada where many sleep clinics are restricted to large urban centers that may not be accessible for many families. Additionally, there are some areas of Canada (e.g., the Maritimes) where no pediatric sleep clinics currently exist. While there may be adult sleep clinics available, these centers often do not have the capacity to evaluate pediatric patients. Clearly there is a need to explore alternative methods of service delivery, such as building capacity among non-sleep specialist health professionals. Part of supporting these professionals may include the opportunity for consultation, which was another common theme within the facilitators reported. Health professionals referred both to consultation with other health professionals (coded as practice setting facilitators) and sleep specialists. Health care institutions could identify individuals with expertise in behavioral sleep interventions, or willingness to develop expertise in this area, and allocate time and resources so that these individuals can provide sleep and behavioral sleep consultation. Until this type of consultative capacity is built within institutions, Web-based and telehealth consultation may be provided between institutions or service levels (for an example of the role of telehealth in pediatric sleep, see Witmans et al., 2008). While many of the facilitators reported were positive, one area of potential concern was the high incidence of experience (both personal and professional) being reported as a facilitator to practice. Although we recognize that in the absence of more standardized and structured training and educational opportunities health professionals will learn from the sources of information available to them, relying on tools and strategies that have worked with professionals’ own sleep difficulties, those of their children, or those of their patients, can be problematic and may have limited generalizability. Experience cannot be expected to substitute for formal evidence-based training. This provides further support for efforts to increase training and continuing education activities. It also highlights a commendable willingness amongst health professionals to provide sleep-related care despite clear barriers and limited educational support. Given the active effort

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required of health professionals that underlies many of the identified facilitators (e.g., selfdirected learning, consultation) it is likely that our sample includes a number of professionals who could be conceptualized as “champions” of this service area. Additionally, given that individuals who reported facilitators and those who reported both barriers and facilitators had greater number of years of experience working with the population in question and reported being further along in their planned changes to sleep-related practice, it is possible that over time health professionals develop ways of facilitating their practice that more junior clinicians have not had the opportunity to develop. Overall, a common theme present within the responses provided was a difference in the perceived locus of control of health professionals with regard to barriers and facilitators to evidence-based sleep care. Specifically, it appeared that barriers were frequently framed as being due to external factors (e.g., not enough time, systems-level factors, not enough education, parent beliefs conflicting with health professional’s practice) while facilitators were often framed as resulting from internal factors (e.g., self-directed learning efforts, the professional’s own belief that sleep is important). Further research examining how these internal factors can be developed and encouraged could make a meaningful contribution to efforts to increase uptake of sleep-related training opportunities and resources. There were several strengths of this study. While many previous studies have asked pediatric sleep experts to speculate on the barriers to evidence-based sleep care, this study asked nonsleep specialist health professionals working in a variety of health care settings to report directly on their own experiences, and included health professional groups (nurses and social workers) who have not traditionally been recruited in studies of behavioral sleep-related services. Health professionals were asked to identify the barriers and facilitators to their practice in an openended format, rather than imposing the investigators’ hypotheses on the participants in the form of a questionnaire or checklist. This allowed the idea of barriers and facilitators as multidimensional and non-mutually exclusive constructs to emerge. For example, individual health professionals could, and did, endorse barriers and facilitators of practice. Participants who responded to both the barriers and facilitators questions generally provided responses that were coded as being in different categories for each (e.g., lack of time and knowledge were identified as barriers, and experience was identified as a facilitator) or identified current barriers and related facilitators that they are currently employing in an attempt to overcome the barrier (e.g., lack of knowledge identified as a barrier, and the participant identified beginning to attend more continuing education as a facilitator). Understanding this complexity will be important for identifying and tailoring effective means of, and opportunities for, facilitating sleep-related care in non-specialty settings. There are also several limitations of this study. Due to the nature of the recruitment methods employed in this study, it is impossible to calculate the overall response rate for this study, as the number of health professionals who saw the e-mail invitation but chose not to participate is unknown. However, it is suspected that the response rate to the survey was extremely low given the far-reaching attempts to disseminate the invitation to participate. As such, the sample of health professionals in this study may not be representative of all non-sleep specialist professionals in Canada, and may over-represent professionals who have an inherent interest in sleep. Additionally, within the larger study, the response rate for the open-ended questions was relatively poor with just over one-half of participants responding to the barriers or facilitators question. As such, the self-motivated facilitators reported (e.g., self-directed

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learning, professional practice orientation) may not be applicable to health professionals who are less invested in sleep, and the barriers highlighted in this study may be amplified in the general population. However, the fact that a relatively equal number of barriers and facilitators were reported could also indicate that individuals who were able to provide evidence-based sleep care were not necessarily over-represented in this sample. Additionally, there were no significant demographic differences between those participants who did and did not answer the open-ended questions. Despite these limitations, we believe that the knowledge gained from this study is an important step towards understanding what is preventing health professionals from providing behavioral sleep care, and illuminates what is working in those settings that are able to provide this care. Previous research has speculated on the possible barriers to evidence-based sleep care; however, this is the first study to our knowledge that has solicited the perspectives of those individuals attempting to provide this care. Future research could employ observational methods to compare the practices of health professionals who report being able to provide evidence-based pediatric sleep care with those who report being unable to provide these services. This may further elucidate practical and systems-level factors that contribute to this issue. Additionally, it may be important to conduct further research to determine how the practice demands and specific barriers and facilitators reported by different professional groups may influence their best fit within a stepped care model. For example, perhaps within the primary/community level of a stepped care model there may be “micro-steps” in which physicians provide screening; nurses provide support for parents undergoing self-administered treatment; and psychologists provide group or individual treatment for those requiring greater focus on cognitive and affective aspects of treatment, more in-depth application of behavior change techniques, or integration of sleep services with other mental health or behavioral health interventions. Finally, further research is needed to design and evaluate training programs for health professionals that address identified knowledge gaps (Boerner, Coulombe, & Corkum, in press), while accounting for barriers such as a lack of time and institutional/systems-level/practice setting factors. This could be accomplished by developing training materials that are concise but that also include education for higher level management to demonstrate the importance of providing evidence-based sleep care and provide health professionals a supportive setting in which to deliver their interventions. Research would be needed to evaluate whether definable practice change has occurred as a result of this training program through chart reviews and observational studies. Research outcomes of greatest significance to institutional stakeholders should also be identified. These may include financial analyses of the costs and benefits of addressing sleep in its own right and as part of the treatment of other health and mental health problems. While the implementation of sleep-related training programs would represent an economic investment, there is growing evidence that, given the profound impact of sleep on health and functioning, not treating sleep presents a substantial economic burden to the healthcare system (Daley et al., 2009; Kapur et al., 2002; Palermo, Law, Churchill, & Walker, 2012). There is a clear need for increased knowledge of behavioral sleep care in pediatric populations. Researchers, clinicians, and policymakers wishing to improve this access to education can draw upon the barriers and facilitators presented in this study to inform their decisions regarding education delivery, required resources and tools, and planning feasible models of service delivery.

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FUNDING Katelynn E. Boerner was supported during this study by an IWK Graduate Student Award, the McCarlie Award from the IWK Health Center, and a doctoral award from the Canadian Institutes of Health Research (CIHR). J. Aimée Coulombe was supported through a postdoctoral fellowship with the CIHR Better Nights Better Days Pediatric Sleep Team in Sleep and Circadian Rhythms. Funding for this research study was provided through an IWK Health Center Category A award. ACKNOWLEDGMENTS We thank the health professionals who participated in this study and disseminated study information, and acknowledge the assistance of Katy Schurman, Erin Maguire, Meredith Bessey, and Melissa Howlett in study preparation and data collection.

REFERENCES Bhargava, S. (2011). Diagnosis and management of common sleep problems in children. Pediatrics in Review, 32, 91–99. Boerner, K. E., Coulombe, J. A., & Corkum, P. (in press). Core competencies for health professionals’ training in pediatric behavioural sleep care: A Delphi study. Behavioral Sleep Medicine. Bruni, O., Violani, C., Luchetti, A., Miano, S., Verrillo, E., Di Brina, C., & Valente, D. (2004). The sleep knowledge of pediatricians and child neuropsychiatrists. Sleep and Hypnosis, 6(3), 130–138. Corkum, P. (Chair), Godbout, G., Hall, W., Reid, G., & Coulombe, A. (2012, December). Canadian perspective on novel ways of treating childhood behavioural insomnia: Outcomes of four behavioral interventions studies that are informing the development of a national Web-based treatment study. Symposium presentation at International Pediatric Sleep Association Congress 2012, Manchester, United Kingdom. Daley, M., Morin, C. M., LeBlanc, M., Gregoire, J. P., Savard, J., & Baillargeon, L. (2009). Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents. Sleep Medicine, 10, 427–438. Elik, N., Corkum, P., McGrath, P., & Kutcher, S. (2009). Randomized controlled trial of a classroom based distance intervention for teachers of elementary school-aged children with ADHD. Nova Scotia Health Research Grants program (Unpublished manuscript). Espie, C. A. (2009). “Stepped care”: A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32, 1549–1558. Gregory, A. M., & O’Connor, T. G. (2002). Sleep problems in childhood: A longitudinal study of developmental change and association with behavioral problems. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 964–971. doi:10.1097/00004583-200208000-00015 Gruber, R., Cassoff, J., & Knauper, B. (2011). Sleep health education in pediatric community settings: Rationale and practical suggestions for incorporating healthy sleep education into pediatric practice. Pediatric Clinics of North America, 58, 735–754. Hill, C. (2011). Practitioner review: Effective treatment of behavioural insomnia in children. Journal of Child Psychology and Psychiatry, 52, 731–741. doi:10.1111/j.1469-7610.2011.02396.x Hseih, H., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Kapur, V. K., Redline, S., Nieto, J., Young, T. B., Newman, A. B., & Henderson, J. A. (2002). The relationship between chronically disrupted sleep and healthcare use. Sleep, 25, 289–296. Meltzer, L. J., Phillips, C., & Mindell, J. A. (2009). Clinical psychology training in sleep and sleep disorders. Journal of Clinical Psychology, 65, 305–318. doi:10.1002/jclp.20545

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Mindell, J. A., Bartle, A., Wahab, N. A., Ahn, Y., Ramamurthy, M. B., Huong, H. T. D., : : : Goh, D. Y. T. (2011). Sleep education in medical school curriculum: A glimpse across countries. Sleep Medicine, 12, 928–931. doi:10. 1016/j.sleep.2011.07.001 Mindell, J. A., Kuhn, B., Lewin, D. S., Meltzer, L. J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep: Journal of Sleep and Sleep Disorders Research, 29, 1263– 1276. Mindell, J. A., Moline, M. L., Zendell, S. M., Brown, L. W., & Fry, J. M. (1994). Pediatricians and sleep disorders: Training and practice. Pediatrics, 94, 194–200. Moore, M. (2012). Behavioral sleep problems in children and adolescents. Journal of Clinical Psychology in Medical Settings, 19(1), 77–83. doi:10.1007/s10880-011-9282-z Owens, J. (2001). The practice of pediatric sleep medicine: Results of a community survey. Pediatrics, 108, e51. Owens, J. (2008). Classification and epidemiology of childhood sleep disorders. Primary Care: Clinics in Office Practice, 35, 533–546. Owens, J., Jones, C., & Nash, R. (2011). Caregivers’ knowledge, behaviour, and attitudes regarding healthy sleep in young children. Journal of Clinical Sleep Medicine, 7, 345–350. Owens, J., Kothare, S., & Sheldon, S. (2012). “Not just little adults”: AASM should require pediatric accreditation for integrated sleep medicine programs serving both children (0–16 years) and adults. Journal of Clinical Sleep Medicine, 8, 473–476. Owens, J., & Mindell, J. (2006). Pediatric sleep medicine: Priorities for research, patient care, policy and education. Journal of Clinical Sleep Medicine, 2, 77–88. Palermo, T., Law, E., Churchill, S. S., & Walker, A. (2012). Longitudinal course and impact of insomnia symptoms in adolescents with and without chronic pain. Journal of Pain, 13, 1099–1106. Papp, K. K., Penrod, C. E., & Strohl, K. P. (2002). Knowledge and attitudes of primary care physicians toward sleep and sleep disorders. Sleep Breathing, 6(3), 103–109. Peachey, J. T., & Zelman, D. C. (2012). Sleep education in clinical psychology training programs. Training and Education in Professional Psychology, 6(1), 18–27. doi:10.1037/a0026793 Piccione, P. M., & Barth, R. P. (1983). Sleep: An expanding field of practice and research. Social Work, 28, 228–233. Prochaska, J. O., & DiClemente, C. C. (1985). Common processes of self-change in smoking, weight control, and psychological distress. In S. Shiffman & T. Wills (Eds.), Coping and substance abuse: A conceptual framework (pp. 345–363). New York, NY: Academic. Rosen, R., Rosekind, M., Rosevear, C., Cole, W. E., & Dement, W. C. (1993). Physician education in sleep and sleep disorders: A national survey of U.S. medical schools. Sleep, 16, 249–254. Rosen, R., & Zozula, R. (2000). Education and training in the field of sleep medicine. Current Opinion in Pulmonary Medicine, 6, 512–518. Sadeh, A., Gruber, R., & Raviv, A. (2003). The effects of sleep restriction and extension on school-age children: What a difference an hour makes. Child Development, 74, 444–455. doi:10.1111/1467-8624.7402008 Witmans, M. B., Dick, B., Good, J., Schoepp, G., Dosman, C., Hawkins, M. E., : : : Witol, A. (2008). Delivery of pediatric sleep services via telehealth: The Alberta experience and lessons learned. Behavioral Sleep Medicine, 6, 207–219. doi:10.1080/15402000802371312

APPENDIX 1: CODES FOR BARRIERS 1. Lack of knowledge, skills, techniques, training, or education This code refers to any barrier relating to a lack of knowledge, skills, techniques, or education on any topic relevant to evidence-based behavioral sleep care. This includes knowledge of sleep in general, behavioral interventions in general, and behavioral interventions specific to pediatric sleep. This also includes knowledge related to specific populations. Education can refer to both past education (e.g., in graduate school, medical school), as well as opportunities for continuing education.

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2. Lack of resources and materials This code refers to a lack of resources for any reason. This includes both resources for health professionals, as well as for parents. Resources can be lacking due to availability of such resources, access to such resources, lack of evidence-based resources, and so forth. 3. Lack of time This code refers to any barrier related to lack of time, including lack of time with patients (e.g., to address/assess problem or for follow up), as well as lack of time for professional activities to further one’s own education about pediatric sleep. 4. Institutional/system-level/practice-setting barriers This code refers to any barrier related to limits placed on the provider by institutional factors (e.g., institutional practices, approaches, and beliefs), systems-level factors (e.g., lack of support from management, financial support), or the practice-setting barriers (e.g., patients with sleep problems not seen in this setting, constraints related to a specific setting such as working in an emergency department, lack of opportunity to consult with colleagues who are not explicitly identified as sleep specialists). 5. Lack of access to sleep specialists/sleep services This code refers to any barrier related to a lack of access to sleep services or sleep specialists, either for consultation or referral. 6. Barriers related to parents, mismatch between parent and health provider or setting This code refers to any barrier that is related to the parents (e.g., parental beliefs, cognitions, expectations, resistance, lack of implementation of suggested strategies, parental symptoms, medical conditions, parents do not identify sleep as presenting problem, etc.), as well as any mismatch between parents and health providers or settings (e.g., cultural differences). 7. Barriers related to individual practice and professional orientation This code refers to any barrier placed on the provider by themselves with regards to the individual’s own practice and professional orientation (e.g., sleep not seen as a priority by the professional, outside of what they believe to be their role). 8. Lack of experience This code refers to a lack of experience, which includes both professional experiences (e.g., clinical, research), as well as personal experience (e.g., dealing with sleep issues in their own children, or their own insomnia). 9. Other Any barrier that does not clearly fit into one of the above categories.

APPENDIX 2: CODES FOR FACILITATORS 1. Knowledge, skills, techniques, training, or education This code refers to any facilitator relating to knowledge, skills, techniques, or education on any topic relevant to evidence-based behavioral sleep care. This includes knowledge of sleep in general, behavioral interventions in general, and behavioral interventions specific to pediatric sleep. This also includes knowledge related to specific populations.

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2.

3.

4.

5.

6.

7.

8.

9.

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Education can refer to both past education (e.g., in graduate school, medical school), as well as opportunities for continuing education (e.g., self-directed learning, workshops, conferences, talks, conducting research, teaching). Resources and materials This code refers to any facilitator relating to resources for health professionals, as well as for parents. Time This code refers to any facilitator related to time, including time with patients (e.g., to address/assess problem or for follow-up), as well as time for professional activities to further one’s own education about pediatric sleep. Institutional/systems-level/practice-setting facilitators This code refers to any facilitator related to institutional factors (e.g., institutional practices, approaches, beliefs), systems-level factors (e.g., support from management, financial support), or the practice setting (e.g., opportunities to use sleep-related skills/knowledge, indicated need from clients, opportunity to consult with colleagues who are not explicitly identified as sleep specialists). Access to sleep specialists/sleep services This code refers to any facilitator related to access to sleep services or sleep specialists, includes for consultation or referral. Facilitators related to parents This code refers to any facilitator related to the parents (e.g., parent willingness, commitment, adherence), as well as the relationship between the health provider and the family. Facilitators related to individual practice and professional orientation This code refers to any facilitators related to the individual’s own current practice and professional orientation, such as their own beliefs and convictions about sleep, making sleep a priority in their practice, and so forth. Experience This code refers to any previous experience identified by the individual, which includes both professional experiences (e.g., clinical, research), as well as personal experience (e.g., dealing with sleep issues in their own children or their own insomnia). Other Any facilitator that does not clearly fit into one of the above categories.

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