THE USE OF BRIEF COGNITIVE BEHAVIORAL THERAPY INTERVENTIONS
IN THE TREATMENT OF CHRONIC NON-CANCER PAIN IN THE PRIMARY
CARE SETTING
By
Megan Ann Newton
BScN., University of Northern British Columbia, 2011

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE
PRACTITIONER PROGRAM

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2019
© Megan Newton, 2019

ii
Abstract
As one of the foremost causes of healthcare resource consumption and disability among
Canadian adults, chronic non-cancer pain (CNCP) requires significant attention within
healthcare delivery and research. While CNCP treatment is typically guided by
pharmacotherapeutics, current literature illustrates that Cognitive Behavioral Therapy (CBT)
as a CNCP treatment can promote effective pain coping strategies, thereby improving pain
and psychosocial outcomes. Cognitive Behavioral Therapy services are constrained, in
particular due to limited access and referral to mental health professionals who provide these
services. To improve access to CBT services and close gaps in CNCP care, primary care
providers could offer brief CBT in their practices. Brief CBT (bCBT) delivered in primary
care settings would provide active treatment for CNCP as well as interim treatment for
patients awaiting referral to full-service CBT, should that service be required. An integrative
literature review has been conducted to identify if Nurse Practitioners, who work in primary
care settings, can deliver bCBT to improve outcomes in CNCP patients. The results are
discussed within the context of British Columbia (BC) primary care practice. Twelve articles
were reviewed using Whittemore and Knafl’s approach to the integrative literature review.
Results suggest that providers not trained in specific mental health interventions can deliver
bCBT to improve CNCP outcomes. Primary care providers are encouraged to seek out
opportunities for employing bCBT to gain skill and confidence in providing this treatment.
This way, providers can offer multimodal CNCP treatment while also playing an important
role in improving access to CBT services. Recommendations for enhancing care of CNCP
with bCBT are discussed, and specific strategies for its use in primary care are presented.

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Table of Contents
Abstract

ii

Table of Contents

iii

List of Figures

v

List of Tables

vi

Glossary

vii

Abbreviations

xii

Acknowledgements

xiii

Dedications

xiv

Chapter One: Introduction

1

Chapter Two: Background and Context
Pain: Anatomy & Physiology
Types of Chronic Pain
Chronic Non-Cancer Pain Guidelines & Resources
The Cognitive Behavioral Therapy Model
Cognitive Behavioral Therapy & Chronic Non-Cancer Pain
Brief Cognitive Behavioral Therapy & Primary Care
Nurse Practitioner Role in Primary Care in British Columbia

5
6
11
12
14
15
16
17

Chapter Three: Methods
Search Term Identification
Inclusion and Exclusion Criteria
Search Strategy
Approach to Analysis

20
20
21
22
23

Chapter Four: Findings
Provider and Setting
Setting
Primary Care Providers
Effective Brief Cognitive Behavioral Therapy Interventions
Cognitive Behavioral Manual Resource
Adapting Therapy and Engaging Patients
Workbook and Home Activities
Brief Type Interventions
Cognitive Behavioral Therapy Education for Providers
Education Facilitators and Barriers

25
26
27
28
33
33
34
35
36
38
38

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Chapter Five: Discussion
Provider and Setting
Setting
Primary Care Providers
Effective Brief Cognitive Behavioral Therapy Interventions
Cognitive Behavioral Manual Resources
Adapting Therapy and Engaging Patients
Workbook and Home Activities
Cognitive Behavioral Therapy Education for Providers
Recommendations
Limitations and Future Research
Conclusion

41
41
42
44
46
47
48
50
51
53
55
56

Bibliography

59

Appendix A: Concept Map

64

Appendix B: Literature Search

65

Appendix C: Literature Matrix

66

Appendix D: Levels of Evidence

71

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List of Figures
Figure 1: The Homunculus of the Brain

9

Figure 2: The Pain Pathway

10

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List of Tables
Table 1: Key Recommendations for Clinical Practice

54

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Glossary
Afferent Nerves: the type of nerve that carries sensory nerve impulses from the periphery
towards the central nervous system.
Allodynia: a pain resulting from a stimulus (such as a light touch of the skin), which would
not normally provoke pain.
Brief Cognitive Behavioral Therapy: the compression of CBT material and the reduction of
the average 12-20 sessions into four to eight sessions, or shortened sessions of 10-30
minutes.
Central Nervous System: consists of spinal cord and brain; also responsible for integrating
sensory information and responding accordingly.
Chronic Non-Cancer Pain: a pain persisting beyond three months, which is not associated
with cancer or the end of life.
Cognitive Behavioral Therapy: a form of psychotherapy based on the notion that thought
distortions and maladaptive behaviours play a role in psychological disorders. The
focus is on developing coping strategies and changing unhelpful thoughts, beliefs and
attitudes. It is the most widely used therapy for treating depression in adults, but does
have application for the treatment of chronic pain condition.
Cranial Nerves: the nerves of the brain, which emerge from or enter the skull (the cranium),
as opposed to the spinal nerves, which emerge from the vertebral column. The 12
cranial nerves include: olfactory, optic, occulomotor, trochlear, trigeminal, abducent,
facial, vestibulo-cochlear, glossopharyngeal, vagus, accessory, and hypoglossal.
Dysesthesia: an abnormal unpleasant sensation felt when touched, caused by damage to
peripheral nerves.

viii
Efferent Nerves: a nerve that conveys impulses from the central nervous system toward or to
muscles or glands.
First Order Nerves: nerves that synapse with neurons of another type called lower motor
neurons, which can carry messages to the muscles of the rest of the body.
Ganglia: a mass of nerve tissue containing cell bodies of neurons external to the brain or
spinal cord.
Homunculus: a distorted representation of the human body, based on a neurological "map" of
the areas and proportions of the human brain dedicated to processing motor functions,
or sensory functions, for different parts of the body.
Hyperalgesia: increased sensitivity to pain or enhanced intensity of pain sensation.
Hyperesthesia: an abnormally acute sense of pain, heat, cold, or touch as increased sensitivity
to stimulation.
Hyperpathia: an exaggerated and prolonged painful sensation in response to a normally
innocuous stimulus.
Hypothalamus: a region of the forebrain below the thalamus that coordinates control of body
temperature, thirst, hunger, and other homeostatic systems; also involved in sleep and
emotional activity.
Nurse Practitioner: are Advanced Practice Nurses (APN) that are licensed by the British
Columbia College of Nursing Professionals in the classification Nurse
Practitioner. Nurse Practitioners provide comprehensive clinical care including the
diagnosis and management of disease/illness, prescribing medications,
ordering/interpreting laboratory/diagnostic tests, and initiating referrals to specialists.
Limbic System: a complex system of nerves and networks in the brain, involving areas near

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the cortex concerned with instinct and mood. It controls the basic emotions (fear,
pleasure, anger) and drives (hunger, sex, dominance, care of offspring).
Neuropathic Pain: a pain initiated or caused by a primary lesion, dysfunction, of transitory
perturbation of the peripheral or central nervous system
Nucleus Raphe Magnus: function is mostly pain mediation; it sends projections to the spinal
cord to directly inhibit pain. It releases serotonin when stimulated.
Periaqueductal Grey: primary control center for descending pain modulation. It has
specialized cells that suppress pain.
Peripheral Nervous System: the division of the nervous system containing all nerves that lie
outside of the central nervous system (CNS). Its primary role is to connect the CNS
to the organs, limbs, and skin, allowing the CNS to stimulate a reaction to the
provoking stimuli in environment.
Post Central Gyrus: is the location of the primary somatosensory cortex, the main sensory
receptive area for the sense of touch. Like other sensory areas, there is a map of
sensory space in this location called the sensory homunculus.
Primary Care: first-contact care with a health care professional where the majority of nonacute health problems are treated. It is the principal point of continuing care and/or
referral to specialist treatment.
Primary Care Provider: a health care professional, usually a general practitioner or nurse
practitioner, who provides primary care.
Reticular formation: plays a central role in the regulation of the state of consciousness and
arousal. It consists of a complex network of interconnected circuits of neurons.

x
Second order nerves: are cranial and spinal nerves. The cell bodies of these neurons are
located in the brain stem, but their axons can leave the central nervous system and
synapse with the muscles of the body.
Sensory Receptors: is a structure that reacts to a physical stimulus in the environment,
whether internal or external. It is a sensory nerve ending that receives information and
conducts a process of generating nerve impulses to be transmitted to the brain for
interpretation and perception.
Somaesthetic Cortex: region of cerebral cortex receiving the somatic sensory information
from the thalamus; is the primary processing mechanism for sensory information
from the body surfaces and in deeper tissues like muscles and tendons.
Somatosensory Cortex: receives sensory input from the body. Neurons that sense feelings in
skin, pain, visual, or auditory stimuli all send their information to the somatosensory
cortex for processing.
Spinal Nerves: any of the paired nerves which leave the spinal cord of vertebrate, supply
muscles of the trunk and limbs, and connect with the nerves of the sympathetic
nervous system, of which there are 31 pairs.
Spinoreticular Tract: an ascending pathway in the spinal cord. The tract is from spinal cord to
reticular formation to thalamus. It is responsible for automatic responses to pain, such
as in the case of injury.
Spinothalamic Tract: an ascending pathway of the spinal cord. It is responsible for the
transmission of pain, temperature, and crude touch to the somatosensory region of the
thalamus.

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Thalamus: lies between the cerebral hemispheres on either side of the third ventricle, relaying
sensory information and acting as a center for pain perception.

xii
Abbreviations
BCBT: Brief CBT
CBT: Cognitive Behavioral Therapy
CBT-I: Cognitive Behavioral Therapy for Insomnia
CNS: Central Nervous System
FNP: Family Nurse Practitioner
IASP: International Association for the Study of Pain
NP: Nurse Practitioner
NRM: Nucleus Raphe Magnus
PAG: Peri-Aquaductal Grey
PC: Primary Care
PCP: Primary Care Providers
PHC: Primary HealthCare
PNS: Peripheral Nervous System

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Acknowledgements
My sincerest appreciation goes to my advisory committee members, Linda Van Pelt,
MScN, NP-F, and Helen Bourque, MScN, NP-F. Thank you both for the dedication and
support you have provided throughout this process, despite juggling many other
commitments in your lives.
I would especially like to thank Linda Van Pelt for her never-ending patience,
guidance, time, and reassurance during the writing of this project. As my teacher and mentor,
she has taught me more than I could ever give her credit here for. She has shown me, by
example, what a Nurse Practitioner should be.

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Dedications
I would like to dedicate this project first and foremost to Jason, whose unwavering
support, love, and humor have kept me moving forward over the last four years. To my
parents, my own personal cheering crowd, who have encouraged me to keep pushing
forward. Particularly, to my father, for inspiring me to research such an important subject. To
the UNBC faculty, and to my preceptors Diane Middagh, Lori Miller, Leanne Rowand, and
Trien Van for providing me with exceptional learning environments. And finally, to my
classmates, who I cannot thank enough for their friendship and encouragement through these
last few years.

1
Chapter One: Introduction
Chronic non-cancer pain (CNCP) is a complex biopsychosocial phenomenon
experienced by people of all demographics worldwide. It is estimated that one in five
Canadians suffer from CNCP, making it one of the foremost causes of healthcare resource
consumption and disability among Canadian adults (Schopflocher, Taenzer, & Jovey, 2011).
Most notably, symptoms of CNCP impede activities of daily living; diminish physical
capacity and quality of life; and increase health, social, political, and economic burden on
individuals, families, and healthcare systems (Schopflocher et al., 2011). The effective
management of CNCP is therefore a major concern for individuals, their families, society,
and healthcare providers. Chronic non-cancer pain however, presents unique challenges both
physically and psychosocially in terms of approach to treatment and management.
As a child of a CNCP sufferer, I have been privy to the complex biopsychosocial
consequences associated with this condition. I witnessed management strategies that were
available to my father in the primary care setting and became acutely aware of the
management options that were not available due to the rural location of our town. As I move
into the role of a primary care provider, this observation has led me to consider if the barriers
to CNCP management can be addressed by primary care providers (PCPs) integrating both
pharmacotherapeutics and non-pharmacological options, like brief Cognitive Behavioral
Therapy (bCBT) into practice. I also wonder if by doing so, PCPS can improve the quality of
life and function of those with CNCP.
I began a preliminary literature search for this integrative literature review by
gathering information on the biopsychosocial aspects of CNCP, reviewing current primary
care management guidelines for CNCP, and identifying barriers and facilitators to care for

2
CNCP. From this initial review, I found that the primary goal to caring for patients with
CNCP is not the elimination of pain, but rather the improvement of function with an
emphasis on therapies that target the whole person (Bruehl, 2015). Whole person care refers
to management strategies that aim to encompass the individual’s physical, psychological,
social, and functional well-being (Bruehl, 2015). While attending to the whole person is the
primary goal of CNCP care, I discovered that guidelines for CNCP treatment focus largely
on pharmacotherapeutics that target physical pain; this treatment option addresses only the
physical component of the CNCP experience and negates the other aspects of the whole
person (Mills, Torrance, & Smith., 2016).
Cognitive Behavioral Therapy (CBT) is a treatment that can help address all
components of the whole person in CNCP. Traditionally employed in the treatment of
various mental health conditions, CBT as a CNCP treatment can promote effective pain
coping strategies that improves pain, function, and biopsychosocial outcomes (Mills et al.,
2016). Cognitive Behavioral Therapy services are constrained, largely due to limited access
to mental health providers who provide these services (Schopflocher et al., 2011; Ehde,
Dilworth, & Turner, 2014; McHugh, Gordon, & Byrne, 2014). Likewise, significant financial
burden can exist for patients seeking access to CBT services (Ehde et al., 2014). Offering
condensed and briefly delivered CBT interventions within primary care settings could
address these gaps, especially given that primary care is often an initial point of contact for
patients seeking healthcare services (Mills et al., 2016).
Primary care refers to the first level of care and usually the first point of contact for
Canadians with the healthcare system for receiving medical care and health promotion
(Muldoon et al., 2012). According to Mills et al (2016), more than 50% of Canadians with

3
CNCP receive pain care from their family provider. Canadian CNCP patients are also four
times more likely to visit their family provider for pain management than other specialized
pain providers (Schopflocher et al., 2011; Mills et al., 2016). It is therefore not surprising that
many primary care providers report CNCP care as burdensome, time consuming, and
overwhelming (Schopflocher et al., 2011; Mills et al., 2016).
Primary care providers in British Columbia, including Nurse Practitioners (NPs), will
inevitably provide care and management to CNCP patients (Schopflocher et al., 2011; Mills
et al., 2016). By introducing and offering brief CBT (bCBT) interventions as a treatment
option within their primary care practices, NPs can reduce barriers to CBT service access.
The use of bCBT interventions within the primary care context would contribute to improved
quality of life for the patient; have positive effects on their physical and psychosocial
wellbeing, while reducing personal, social, and healthcare burden and costs. There is,
however, limited information among the current CNCP guidelines to guide primary care
providers for use of bCBT interventions in the context of primary care settings (Bruehl,
2015; Schopflocher et al., 2011). Thus, I developed the following question to guide my
research: “Would the integration of bCBT interventions by Nurse Practitioners (NPs), into
their primary care practices, improve function in adults with CNCP?”
In this paper, I will analyze and synthesize the current literature related to the benefits
of attending to the whole person in adults with CNCP; the role of Nurse Practitioners, who
practice in primary care, in managing CNCP; and the use of primary care delivered bCBT. I
will employ an integrative literature review (ILR) approach to illustrate that the gap to using
bCBT interventions in primary care can be addressed by having NPs, who work within this
setting, integrate these interventions into their practice for CNCP treatment.

4
Chapter two of this paper will address the background and context relevant to this
topic by breaking down the research question. The chapter will include an exploration of pain
and CNCP anatomical, physiological, and pathological mechanisms; the CBT model and
CBT for treatment of CNCP; the use of bCBT interventions in the primary care setting; and
the practice context of NPs as primary care providers in the delivery of bCBT to patients with
CNCP. Chapter three will outline the approach to this project, describing the literature review
methods. In chapter four, the findings from a critical analysis of the literature are discussed.
In this chapter, themes found among the literature that address the research question will be
analyzed. In chapter five, a synthesis and discussion of the findings, including
recommendations for primary care practice will be presented. Finally, the limitations of this
paper will be presented and I will highlight areas for further research.
Nurse Practitioners who work in primary care settings will recognize that an
integrated multimodal approach to CNCP management is not only achievable within the
primary care setting, but also provides CNCP patients with treatment options that would have
been delayed or not otherwise offered. Without an integrated approach, sufferers of CNCP
are left to grapple with the ambiguity as to why they continue to have pain and why that pain
cannot be adequately treated.

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Chapter Two: Background and Context
Beyond being a major chronic condition across all demographics worldwide, chronic
non-cancer pain (CNCP) affects approximately 15-19% of Canadians, a prevalence that tends
to increase in Canada’s aging society (Schopflocher et al., 2011; Mills et al., 2016). In
Canada, CNCP is linked to significant disease burden including: reduced quality of life,
poorer health outcomes, and premature mortality (Mills et al., 2016). It is also one of the
most common morbidities to co-occur with other long-term conditions, with eighty-eight
percent of CNCP patients also suffering from other chronic illnesses (Mills et al., 2016). In
particular, 20–50 % of CNCP patients will also suffer from co-morbid depression, anxiety,
and/or insomnia (Mills et al., 2016). As such, individuals with CNCP will make more
primary care visits (12.9 visits per year) and have longer hospital stays (3.9 days) than
individuals without CNCP (Lalonde et al., 2014). Given the healthcare usage by those with
CNCP, significant economic burden exists. As of 2011, CNCP has been associated with an
annual cost that exceeds $43 billion dollars (Lynch, 2011; Busse, 2017). Of patients with
CNCP, at least 40% being treated in a routine practice setting will fail to achieve
functionality (Schopflocher et al., 2011; Mills et al., 2016).
While treatment options for CNCP have historically been unimodal, largely with
pharmacotherapeutics, the risk of adverse effects makes long-term pharmacological treatment
controversial (Mills et al., 2016). The risk of abuse and overdose-related fatalities associated
with opioid analgesics in particular, is especially concerning (Manchikanti et al., 2012;
Busse, 2017). Although evidence for the efficacy of opioids in the treatment of severe, postsurgical, or acute pain exists, little evidence supports long-term opioid use in CNCP (Busse,

6
2017; Clair, 2017). Due to the complex nature of CNCP, unimodal interventions are
insufficient in achieving the whole person care approach that CNCP requires.
Multimodal strategies that address the physical, psychological, social, and functional
components of CNCP have been shown to be the most efficacious approach to management
compared to pharmacotherapeutics alone (Chou et al., 2009; Clair, 2017; Busse, 2017).
Substantial literature identifies CBT as a prevailing therapy in CNCP, with an ability to
address both the physical and psychosocial components of CNCP (Chou et al., 2009; Clair,
2017; Busse, 2017). However, CNCP practice support guidelines for integrating nonpharmacological treatments like brief CBT (bCBT) into CNCP care are limited (Busse, 2017;
Clair, 2017). Those guidelines that are accessible to primary care providers are often geared
towards strategies for pharmacotherapeutics management (Chou et al., 2009; Clair, 2017;
Busse, 2017). Given that approximately half of patients experiencing CNCP are managed in
a primary care setting, it is imperative for primary care providers, like Nurse Practitioners
(NPs), to be equipped with strategies and resources for integrating bCBT interventions
(Schopflocher et al., 2011; Mills et al., 2016). Through evidence-based practice support
guidelines for integration and delivery of bCBT interventions, NPs will have an arsenal of
multimodal approaches for CNCP treatment.
This chapter will review the anatomical, physiological, and pathological mechanisms
of pain and CNCP, guidelines for CNCP, an overview of CBT, the use of bCBT interventions
in primary care settings, and the practice context of NPs as primary care providers.
Pain: Anatomy & Physiology
The basic experience of pain, also known as nociception, is a physiological
mechanism for self-protection and survival, which results from both physical and

7
psychological responses to an injury on the body (Martini, Nath, & Bartholomew, 2015). As
experienced by most people, pain is a subjective experience with two interdependent aspects.
The first aspect of the pain experience is a localized sensation in a particular body part
(Martini et al., 2015). The second aspect is an unpleasant quality of varying severity
associated with behaviors directed at relieving or terminating that first aspect (Martini et al.,
2015). The basic anatomy and physiology of nociception will be discussed below.
Pain arises from damaged tissue in the peripheral nervous system (PNS) and is
conveyed to the central nervous system (CNS). The CNS is comprised of the brain and spinal
cord, and is where information is processed and responses to painful stimuli originate. The
PNS includes the parts of the nervous system outside of the brain and spinal cord like: cranial
and spinal nerves, ganglia, and sensory receptors. While three main nerve fibres exist in the
nervous system, only two types are involved in the process of pain: the afferent and efferent
nerves. Afferent nerve fibres are described as sensory neurons in the PNS that transduce
information concerning mechanical, thermal, and chemical states in the body to the CNS.
Efferent nerve fibres differ in that these neurons transmit signals from the CNS to effectors.
Effectors are any part of the body that produce a response, such as muscles. Afferent nerve
fibres are further described in terms of being first, second, or third order. First order nerve
fibres, also known as first order neurons, conduct impulses from cutaneous and sensory
receptors to the brain and spinal cord; they are located in the dorsal root ganglion, which are
clusters of neurons in the spine (Martini et al., 2015). Second order neurons transmit
impulses to the thalamus and the cerebellum; they are located in the dorsal horn of the spine
(Martini et al., 2015). Third order neurons conduct impulses to the somatosensory cortex of
the cerebellum and are located in the thalamus (Martini et al., 2015).

8
The process of pain begins when damaged cutaneous or sensory cells in the body
release nociceptor-sensitizing substances causing a current to be generated. This is known as
an action potential, in which an electrical potential is maintained by the transport of
potassium ions into the cell and sodium ions out of the cell (Martini et al., 2015). In response
to a stimulus, there is a change in the nerve cell membrane ion permeability. Once above the
threshold level, the membrane becomes depolarized. Sodium channels open and sodium
enters into the cell, increasing depolarization and causing the membrane potential to increase
(Martini et al., 2015). Depolarization spreads along the nerves and action potentials are
propagated along the first order neurons into the spinal cord (Martini et al., 2015). The spinal
cord connects first order neurons to second order neurons. During the synapse between the
first and second order neurons, a number of excitatory neurotransmitters are released. These
excitatory substances cause the depolarization of second order afferent neurons, which
transmit the pain impulse by ascending to the brain via two major pathways: the
spinothalamic tract and the spinoreticular tract (Martini et al., 2015) (see Figure 2.)
In the spinothalamic tract, second order afferent neurons ascend to the thalamus and
synapse with third order afferent neurons (Martini et al., 2015). The thalamus is responsible
for recognizing how much pain to generate based on the amount of impulses. From the
thalamus, third order afferent neurons project to the primary and secondary somatosensory
cortex, which consists of the post-central gyrus (Martinin et al., 2015). The somatosensory
cortex is organized with a representation of body structures represented upside down, called a
homunculus (see Figure 1.) (Martini et al., 2015). Essentially, the third order neurons project
the pain impulse to the corresponding part of the body in the somatosensory cortex where the

9
pain impulse was started. The post-central gyrus is the site where processing of pain
localization, intensity, quality, and sensory integration takes place at the conscious level.

Figure 1. The homunculus of the brain where body structures represented upside down in the somatosensory
cortex. Reprinted from Neurovascular Disease (pp. 396) by T.M. Gabay & D. Ledet, 2017, Kansas City:
Springer. Copyright 2017 by Springer International Publishing AG. Reprinted with permission.

Pain signals relayed from the spinal cord to the reticular formation occur via the
spinoreticular tract. This pathway is involved in the emotional aspects of pain (Martini et al.,
2015). Second order afferent nerve fibres also ascend the spinal cord to reach the brainstem
reticular formation, before projecting to the thalamus (Martini et al., 2015). These signals are
transmitted through the spinoreticular tract to the thalamus, which in turn projects to the
primary somaesthetic cortex. It also relays information to the hypothalamus and the limbic
system (Martini et al., 2015). The projections through the reticular formation function by
creating arousal in response to a painful stimuli, whereas the projections to the hypothalamus
and limbic system have an important function in the autonomic reflex (i.e. tachycardia), and
emotional (i.e. suffering) responses to a painful experience (Martini et al., 2015).
Two important areas of the brainstem are involved in modulating and reducing pain:
the periaquaductal grey (PAG) and the nucleus raphe magnus (NRM) (Martini et al., 2015).

10
Both of these centres contain high concentrations of opioid receptors and endogenous
opioids, which when stimulated by an electrical pain impulse produce profound analgesic
effects (Martini et al., 2015). A second descending system of serotonin-containing neurons
exists. It is thought that the serotonin released by pain stimulation activates inhibitory
interneurons and thus, blocks pain transmission in the spinal cord (Martini et al., 2015).

Figure 2. The pain-processing pathway. Reprinted from “Evidence and consensus recommendations for the
pharmacological management of pain in India”, G.P. Dureja, R.N. Iyer, G. Das, J. Ahdal, & P. Narang, 2017,
Journal of Pain Research, 10, pp. 716. Copyright 2017 by Dove Medical Press Ldt. Reprinted with permission.

Some injuries to the body will lead to persistent pain that becomes chronic in nature.
Chronic pain serves no purpose and while the exact mechanisms involved in its
pathophysiology are complex, some aspects remain unclear (Huether et al., 2014; Martini et

11
al., 2015). It is therefore important to recognize what chronic pain is and the types that arise
from injuries to the body.
Types of Chronic Pain
Chronic non-cancer pain is defined by the International Association for the Study of
Pain (2008) as a pain persisting beyond the normal healing time, usually three months or
longer, and that is not associated with malignancy, illness, or injury. Fundamentally, chronic
pain can be divided into chronic nociceptive and neuropathic pain. Both types of chronic pain
will be described below.
Chronic nociceptive pain occurs by two mechanisms: a benign pathology or by cancer
cells that grow and crowd other body parts (Martini et al., 2015). This type of chronic pain
can be subdivided into: somatic pain and visceral pain, depending on the body location of the
chronic pain mechanism. Somatic pain is pain that occurs from the bone, joint, skin, or
connective tissue while visceral pain occurs from inflamed or obstructed visceral organs, like
the gastrointestinal tract (Martini et al., 2015). Pain that arises from these areas and that
persists beyond the expected healing time becomes chronic nociceptive pain. For example,
over time and through normal wear and tear, cartilage that surrounds the joints of the spine
can become worn out. The joints can then become inflamed and the patient develops
osteoarthritis in the spine. That inflammation creates painful movement and can be a source
of constant pain. No damage to the nerve or nervous system has occurred, making this type
of pain chronic nociceptive pain (Martini et al., 2015).
Neuropathic pain is fundamentally different from chronic nociceptive pain and is
much more complex (Martini et al., 2015). This type of pain is generated or sustained by the
nervous system; it can either relate to changes in the peripheral or central nervous systems

12
(Martini et al., 2015). In the peripheral nervous system, there are three main mechanisms to
consider: disorders that result in spontaneous firing of damaged nerve fibres, processes that
result in oversensitivity of afferent pathways due to denervation (loss of nerve fibre supply),
and sympathetically maintained pain whereby the sympathetic nervous system secretes
inflammatory substances that sensitize nerve fibres (Martini et al., 2015). Of the processes in
the central nervous system, there may be sensitization at the synaptic level or through
reorganization of higher processing mechanisms (Martini et al., 2015). Symptoms unique to
neuropathic pain include: allodynia, hyperalgesia, hyperpathia, hyperesthesia, and
dysesthesia. Under normal circumstances, the pain sensory system returns to a normal
functional state as soon as the injury begins to heal. However, many features of sensitization
(neuropathic) or chronic inflammation/injury (nociceptive) may persist and will be
manifested as chronic pain and CNCP.
Diagnosis of CNCP can be difficult and must be carried out in a systematic manner
(Martini et al., 2015). Management of these conditions is very individualized in that what
works well for one may not work for the next (Martini et al., 2015). Although practice
guidelines for CNCP exist, there are gaps in the support for providers.
Chronic Non-Cancer Pain Guidelines and Practice Resources
Current practice guidelines are fundamental in supporting primary care providers who
treat and manage complex chronic conditions like CNCP. Although there are several CNCP
guidelines to assist providers in the management of patients with CNCP, significant gaps
concerning the integration of non-pharmacotherapeutic options, like bCBT interventions
exist within these guidelines.

13
Current BC guidelines for the management of CNCP in primary care are: The British
Columbia Guidelines, which redirects the user to The British Columbia Provincial Academic
Detailing (BC PAD) website, The Canadian Guidelines for Opioids for Chronic Non-Cancer
Pain, and The Center for Effective Practice Guidelines (BC PAD, 2013; Busse, 2017; Clair,
2017). These guidelines available to BC primary care providers for CNCP management are
geared towards reduction management strategies for opioids and pharmacotherapeutics (BC
PAD, 2013; Busse, 2017; Clair, 2017). Non-pharmacological interventions are often omitted
and when discussed, are brief and geared towards physiotherapy and/or computer delivered
CBT interventions (BC PAD, 2013; Busse, 2017; Clair, 2017). They do not offer guidance as
to when or who can provide treatments like bCBT or how it can be done within a primary
care setting by providers not otherwise trained in specific mental health interventions (BC
PAD, 2013; Busse, 2017; Clair, 2017). It is therefore not surprising that primary care
providers often report CNCP management as burdensome with concerns regarding
inadequate CNCP training, patient prescription abuse, diversion of prescribed opioids, and
patient opioid addiction (Mignogna et al., 2014).
Providing CBT in primary care settings can be challenging. As Blount (2009) points
out, there are a great number of differences between working as a psychotherapist in a mental
health setting versus being a primary care provider delivering specific mental health services.
Since 2009, resources and tools have emerged from research that gives providers a
framework for providing bCBT within the PC context. In particular, tools in the form of CBT
guided manuals and mental health support modules are available to BC PCPs (General
Practice Services Committee [GPSC], 2015). Current CNCP guidelines need to reflect the
availability of these tools and provide strategies for their implementation in practice.

14
Likewise, strategies that facilitate implementation of these CBT manuals need to be
approachable and feasible within the primary care context.
The Cognitive Behavioral Therapy Model
Cognitive Behavioral Therapy (CBT) is a well-established type of psychotherapy that
is traditionally employed in the treatment of mental health conditions like depression and
anxiety (Blaine et al., 2013). It also has applicability and efficacy in the treatment of many
other conditions like: substance use disorder, insomnia, and chronic pain. Cognitive
Behavioral Therapy is aimed at empowering patients by teaching them the skills to challenge
and offset their psychological and physical conditions (McGinn, 2000; Baker, 2016). Two
aspects of CBT exist: a cognitive aspect and a behavioral aspect.
The cognitive aspect behind CBT is that the patient’s thoughts about a situation, not
the situation itself, affect how the patient feels and behaves (David, 2010; Baker, 2016).
Patients are taught to reframe thoughts and recognize that it is not the situation that causes
the patient’s feelings and behaviours, but rather the meaning the individual gives to the
situation. The behavior aspect of CBT involves strategies that promote behavior activation by
identifying and changing behaviors that maintain or worsen symptoms (David, 2010; Baker,
2016). In essence, CBT involves: 1) learning that mood, behaviors, thoughts, and physical
reactions are all connected and that changing one will affect the others; 2) learning to
recognize thoughts that perpetuate symptoms and challenge them; and 3) behavior activation
strategies (David, 2010; Baker, 2016). Patients are educated about specific techniques, such
as deep breathing exercises, that they can strategically use on their own when feeling
distressed (Baker, 2016).

15
Altering thoughts and behaviors that perpetuate pain symptoms to thoughts that
support positive change in symptoms is a powerful strategy to break the vicious cycle of the
behaviors that worsen CNCP. Differing populations, age groups, and patients with
psychological and/or physical conditions can find CBT effective (Blaine et al., 2013). When
adapted for PC settings, CBT can be an effective treatment for chronic conditions like CNCP.
Cognitive Behavioral Therapy & Chronic Non-Cancer Pain
Cognitive Behavioral Therapy for CNCP is predicated on the notion that to
understand pain, the individual must also consider the cognitive and behavioral factors that
influence the pain experience (Weisberg & Magidson, 2016). Through CBT interventions,
individuals with CNCP can reduce pain, restore loss of function, enhance whole person wellbeing, and decrease reliance on healthcare systems (Weisberg & Magidson, 2016).
The goal of CBT for pain disorders is to redefine the patient’s idea of pain from “pain
means tissue damage” to the idea that all pain is perceived as real by the patient, and that
multiple factors influence that perception of pain, regardless of whether a physical source is
found (Mills et al., 2016). Treatment goals are also to help the patient see themselves as a
well person who has pain and to decrease the preoccupation with pain (Mills et al., 2016).
Individuals are taught to decrease ineffective behaviours, increase adaptive behaviours,
correct ineffective thoughts and beliefs, and increase self-efficacy (Mills et al., 2016).
Through this therapy, the patient understands that pain is a stressor and, as with other
stressors, coping and adaptation must occur (Mills et al., 2016).
Brain imaging studies have allowed researchers to confirm the positive effects
psychological modulation of pain has on brain neuroplasticity (Bushnell et al., 2013).
Neuroplasticity is the capacity of the nervous system to change its structure and function in

16
response to persistent changes in its environment (Bushnell et al., 2013). The following
cellular mechanisms underlie neuroplasticity: axonal growth and guidance resulting in the
formation of new or restored neuronal networks; synaptogenesis resulting in formation of
new synapses; synaptic pruning resulting in the elimination of inappropriate synapses;
transmission changes resulting in modulation of synaptic efficacy; and neurogenesis leading
to turnover of new neurons in certain brain areas (Bushnell et al., 2013). Learning processes,
as those employed in CBT, can be used to build new adaptive pain-coping associations (e.g.,
pain acceptance, self-efficacy, resilience, paced activity) that serve to promote positive
neuroplasticity changes noted above (Bushnell et al., 2013).
Despite the evidence in favour of bCBT type interventions for whole person care in
CNCP, bCBT type interventions are not routinely offered in primary healthcare settings
(Blaine et al., 2013). As a result, patients who may benefit from bCBT treatments are not
able to access this service.
Brief Cognitive Behavioral Therapy Interventions & Primary Care
While patients with CNCP turn to primary care providers for pain management,
studies show that a substantial variability exists in the way providers approach and treat
CNCP (Mignogna et al., 2014; Schopflocher et al., 2011; Mills et al., 2016). In their 2014
study, Mignogna et al found that primary care providers believe that more than one-half of
their CNCP patients are receiving suboptimal care within their practices. As previously
noted, bCBT interventions have favourable outcomes in CNCP, but the lack of timely access
to mental health professionals and services leaves a large gap in care for CNCP patients.
The availability of pain services including CBT services, drastically varies by
community and may depend on the number of local practitioners who have specialized

17
training and interest in CNCP management (Farmanara, Machildon, & Quesnel-Vallee,
2016). In addition, access to mental health and specialized pain care varies across the
province and is often constrained by significantly lengthy wait times (Farmanara et al.,
2016). Access to CNCP services is particularly limited for vulnerable and low-income
populations and those in rural and remote regions of British Columbia (Farmanara et al.,
2016). Not only is CNCP management in the community preferred by most patients, it is also
comparatively less expensive than attending interventions in specialized healthcare facilities
(Farmanara et al., 2016).
In recent years, CBT methods have been adapted to be deliverable in shorter
appointments that are more typical for a clinic practice (Mills et al., 2016). Some of the basic
principles and techniques of CBT can be applied even in a ten-minute appointment (Mills et
al., 2016). This is known as brief CBT (bCBT). Though short in nature, bCBT provides
active treatment to address symptoms of CNCP and can help stabilize symptoms and restore
some physical and psychosocial function to the patient while they wait for specialized or
comprehensive mental health services, should those services be required (Mills et al., 2016).
Primary care providers, like Nurse Practitioners, are in a position to deliver bCBT
interventions in the primary care setting.
Nurse Practitioner Role in Primary Care in British Columbia
Nurse Practitioners (NPs) are healthcare professionals who provide access to primary
healthcare in Canada. Nurse Practitioners are prepared at a master’s degree level, with a
growing number of NPs pursuing and completing doctorate degrees (College of Registered
Nurses of British Columbia [CRNBC], 2016). Depending on their focus of practice, NPs
develop and sustain partnerships with clients of all ages (CRNBC, 2016). With a scope of

18
practice that often overlaps with the scope of a General Practitioner, Nurse Practitioners
provide patients with comprehensive and longitudinal person-focused care (CRNBC, 2016).
Nurse Practitioners also provide first contact assessment for new health care needs; and
referral and coordination of care when it must be sought elsewhere (CRNBC, 2016). Their
competencies within their legislated scope of practice allow NPs to autonomously diagnose
conditions, order and interpret diagnostic tests, prescribe pharmaceuticals, and perform
specific skills (CRNBC, 2016). Nurse Practitioners also provide patients with counselling,
health promotion, and community-based wellness programs (CRNBC, 2016).
The role of Nurse Practitioners who work in primary care is one of the fastest
growing advanced practice nursing roles in Canada. In 2018, the government of British
Columbia announced the creation of 200 new NP positions to support patients in primary
care (British Columbia Government News, 2018). This rapidly evolving role of the NP
represents opportunities to overcome some of the identified barriers to implementing bCBT
interventions into primary care settings.
Nurse Practitioners have a biomedical knowledge with philosophical underpinnings
that align with nursing (CRNBC, 2016). Nurse Practitioners therefore have much
foundational knowledge related to health coaching and therapeutic communication skills, as
well as parts of CBT itself, perhaps without recognizing them as CBT in nature (CRNBC,
2016; Broderick et al., 2012). For example, strategies that encourage patients to refocus
thoughts and behaviors into action items like mindfulness exercises are based on foundations
of CBT interventions (Broderick et al., 2012). In other words NPs, as primary care providers,
have the foundation on which bCBT intervention skills can build upon.

19
The provision of whole person care is foundational to the NP’s practice; addressing
CNCP beyond pharmacological treatments will help to lessen the burden of chronic illness
on individual health, families, society, and the healthcare system. Following the steps within
the integrative literature review process, a comprehensive literature search was conducted to
obtain studies for review, analysis, and synthesis. The methodology for this process will be
described in the next chapter.

20
Chapter Three: Methods
According to Torraco (2005), an integrative literature review is a research approach
that reviews, critiques, and synthesizes literature on a specific topic in an integrated way,
whereby new frameworks and perspectives on that topic are illustrated. This allows
healthcare professionals to generate a complete representation of health and human
experiences that are particularly salient to research and practice. I performed an initial review
of the literature on CNCP management in the primary care setting to determine where gaps in
the evidence existed. Following this primary search, my topic was directed by the question:
“Would the integration of bCBT interventions by Nurse Practitioners (NPs), into their
primary care practices, improve function in adults with CNCP?” Through a synthesis of the
literature, the aim of this review was to generate recommendations for future NP practice.
A literature search was performed following Whittemore and Knafl’s (2005)
methodological approach by: 1) identifying key terms, 2) searching those key terms in
designated search databases, 3) evaluating the results of those searches based on set criteria,
and 4) a critical appraisal of the final chosen articles.
Search Term Identification
My literature search began by searching the University of Northern British Columbia
library databases: CINAHL (EBSCOhost), Medline (EBSCOhost), PubMed (Ovid),
PsychINFO (EBSCOhost), and PsychARTICLE (EBSCOhost). To identify the search terms,
I created a concept map (see Appendix A). A concept map can direct the researcher to
appropriate databases and verify the need for the study or provide information to refine the
research topic (Greenlee & Rice, 2013). Three keywords were identified: chronic non-cancer
pain, primary care provider, and brief Cognitive Behavioural Therapy.

21
The first term identified from the concept map was Concept A: chronic non-cancer
pain. I recognized early in this research process that several CNCP conditions exist, and thus,
chronic non-cancer pain was searched as a broad term to not shift the research focus to a
singular chronic pain condition. Two additional terms were identified as homogenous with
CNCP and included: persistent pain, and long-term pain. Because CNCP conditions exert
influence on the psychosocial well-being of sufferers, the associated terms depression,
anxiety, and insomnia were also evaluated to identify applicable studies. The second term
identified by the concept map was Concept B: primary care provider. Due to the overlapping
scope of practice that exists between Nurse Practitioners and General Practitioners who work
in primary care settings, the terms General Practitioner and Nurse Practitioner were utilized.
Finally, Concept C: Cognitive Behavioral Therapy was the last identified term from the
concept map. Through an initial survey of the literature, I determined that though CBT is a
specific therapy, different delivery approaches exist. Thus, brief CBT (bCBT) and CBT for
insomnia (CBT-I) were also included to retrieve applicable studies.
Each term was then searched as a keyword using appropriate truncation and wildcard
functions. The option to formulate search terms into MeSH terms within the EBSCOhost
databases was used when applicable. Several terms were identified through MeSH headings
including: behavioral therapy and cognitive therapy. Subject headings were also exploded to
include all relevant subheadings (See Appendix B). To determine which articles would be
suitable for the literature review, inclusion and exclusion criteria were established.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria are the limits placed upon the search based on the
research question. The criteria were applied to the search to find the strongest evidence.

22
Sources published between 2010-2018 were reviewed to capture the full breadth and
evolution of research on the topic. These dates illustrate the significant shift in CNCP
treatment during the last 10 years and the writing of this paper began in January 2018.
English language publications from North America, Australia, New Zealand, and Western
Europe were considered to include relevant sociopolitical and cultural study demographics.
Study populations of adult women and men aged 19-64 were reviewed to capture adults with
CNCP. As the focus of this paper was evaluating adults with CNCP, studies evaluating older
adults and pediatric patients were excluded. To keep the study focused, studies were
excluded if they involved sub-populations such as students, specific ethnic populations, or
immigrants.
Articles were excluded if CBT interventions were delivered solely by mental health
professionals. It was important to choose articles where the primary care provider, who is not
specialized in mental health intervention training, delivered bCBT in order to address the
research question. Articles that had non-primary care type settings were excluded with the
exception of two, which I felt were of value in addressing the research question. Studies that
focused on CNCP as a broad condition were first choice for selection. Depression, anxiety,
and insomnia are frequent sequalae of CNCP, and therefore studies where bCBT was
employed in treatment of these conditions were also included. Studies that evaluated:
substance use disorder, schizophrenia, and bipolar disorder were excluded as to not shift
focus from CNCP.
Search Strategy
The aim of the search strategy was to identify relevant studies and exclude those that
were irrelevant (Gillespie & Gillespie, 2003). The search strategy consisted of searching

23
terms clustered around CNCP, primary care provider, and CBT. Each of these term clusters
were translated into the syntax and vocabulary of each database that was searched.
Truncation was also utilized to find singular and plural forms of keywords, while wildcards
were employed to terms with spelling variations.
Concept A and Concept B were searched through the databases using Boolean AND
to create a relationship between the two concepts. Afterwards, the results from that
combination were then searched with Concept C using Boolean AND to create a relationship
between the first two concepts and Concept C.
A search of the databases yielded a copious 18572 search results. Inclusion and
exclusion criteria were applied, leaving the sample total at 517 sources. The use of citation
management was applied, yielding a left over total of 499 resources. The remaining sample
was reviewed through title scanning with 451 sources being eliminated. Forty-eight articles
remained; the abstracts from each were thoroughly reviewed. Following this review, 12
articles met criteria for inclusion in the literature review (See Appendix B).
Approach to Analysis
The next stage of the literature review was the critical analysis of the final selected
articles. I completed this analysis through the use of a literature matrix where I inputted each
article into a table describing each study’s sample, setting, methods, limitations, strengths,
and important findings (See Appendix C). The Critical Appraisal Skills Program (CASP)
(2013) checklists were used for systematic reviews, randomized control trials (RCTs), case
controls, qualitative, and cohort studies to evaluate each corresponding article for rigor,
validity, and strength of evidence. The CASP tools were utilized as they provide a framework
from which to assess the quality of research and determine strengths and limitations of each

24
study (CASP, 2013). Each paper’s CASP rating are outlined in the literature matrix and can
be referred to while reading the following chapter. Three themes emerged from my review of
the articles: 1) provider and setting, 2) effective brief CBT interventions: facilitators and
barriers, and 3) brief CBT education for providers. The results of this analysis are presented
in the next chapter.

25
Chapter Four: Findings
The purpose of this integrative literature review was to explore the current evidence
surrounding the following research question: “Would the integration of bCBT interventions
by Nurse Practitioners (NPs), into their primary care practices, improve function in adults
with CNCP?” Following a comprehensive search of the literature, 12 articles were selected
and included in this review.
The existing body of literature related to brief CBT (bCBT) interventions in the
treatment of chronic non-cancer pain (CNCP) was primarily composed of both quantitative
and qualitative studies. The quantitative literature employed survey-based and correlational
methodologies, whereby trends and patterns concerning pain, depression, anxiety, and
function outcomes were examined. Phenomenological and case study methodologies were
employed to evaluate data in the qualitative literature. Overall, the participants amongst the
studies were: mostly Caucasian, low to middle class, and comprised of adult men and
women. Limits to the use of CBT interventions in PC settings for CNCP were identified
within this body of literature and will be discussed further below.
Of the twelve articles included in the review, six were conducted in the USA
(Broderick et al., 2014; Buysse et al., 2011; Funderburk et al., 2011; Lewis et al., 2013;
Mignogna et al., 2018; Richmond et al., 2015); two in Norway (Mathieson et al., 2013;
Aschim et al., 2011), one in New Zealand (Junquist et al., 2011); and three from the above
countries as well as Australia and the United Kingdom (Knoerl et al., 2015; Hoifodt et al.,
2011; Dorflinger et al., 2016). These settings represent similar and relevant sociopolitical,
healthcare system, and cultural demographics as Canada. I did acknowledge that limitations
concerning generalizability could exist despite the similarities between countries.

26
The research methods used in the articles are further detailed in the literature matrix
and include: three primary randomized control trials (Broderick et al., 2014; Buysse et al.,
2011; Junquist et al., 2010), three systematic reviews of RCTs (Hoifodt et al., 2011;
Dorflinger et al., 2016; Richmond et al., 2015); one integrative literature review (Knoerl et
al., 2015); one pre-post design study (Mignogna et al., 2018), two case-control studies
(Funderburk et al., 2011; Mathieson et al., 2013) and two cross-sectional studies (Lewis,
2013; Aschim et al., 2011). All studies were assessed for evidence levels based on Melnyk
and Fineout-Overholt’s (2015) work, and ranked from one to seven (See Appendix D).
When considering the strengths of the body of literature being considered, there were
well-designed RCTs, and other types of studies that had adequate patient sample sizes, were
longitudinal, had well-established objective measures for outcomes, and had sound statistical
analysis. Some of the limitations among the body of literature included: some studies having
a limited sample size, and limitations to population type and generalizability of the results. A
more detailed representation pertaining to each study’s sample, setting, methods, limitations,
strengths, important findings, and CASP scores can be found in the literature matrix in
Appendix C and referred to while reading this section.
Through a critical analysis of the findings from each study, the following themes
emerged: 1) provider and setting, 2) effective brief CBT: facilitators and barriers, and 3) brief
CBT education for providers. This chapter will expand on these themes based on the
findings.
Provider and Setting
Provider and setting type were the first themes to emerge from the literature. Nine of
the twelve articles found that CBT interventions, in particular those that were brief and/or

27
adaptable, were successfully employed within the primary care setting by providers who did
not have specific mental health intervention training (Aschim et al., 2011; Broderick et al.,
2014; Buysse et al., 2011; Funderburk et al., 2011; Hoifodt et al., 2011; Junquist et al., 2010;
Lewis et al., 2013; Mathieson et al., 2013; Mignogna et al., 2018). Mixed findings regarding
the efficacy of CBT interventions delivered in PC settings by PCPs was found in one of the
twelve articles, though several contributing factors led to these mixed findings; these will be
described further below (Dorflinger et al., 2016). The last two of the twelve articles did not
remark on the setting type (Knoerl et al., 2015; Richmond et al., 2015).
Setting.
Nine of the twelve studies were completed within a primary care type setting, which
was described as a clinic office type setting in a community. The randomized control trial by
Junquist et al (2010) was completed within both a primary care clinic and local pain
treatment clinic. Given that pain treatment clinics are specialized areas for healthcare
delivery, the aspects of data that pertained to the pain clinic setting were omitted. In the
integrative literature review by Knoerl et al (2015) and systematic review with meta-analysis
by Richmond et al (2015) both studies described the effectiveness of CBT interventions for
CNCP by a variety of providers, though a description of the setting type was omitted within
both articles. While these two articles did not explicitly describe the setting in which CBT
interventions were delivered, both studies illustrated CBT type interventions could be
successfully delivered by both those providers specifically trained and those not specifically
trained in mental health interventions.
Among the theme of setting, two studies found that reorganization of setting practice
was linked to PCP integration of CBT interventions. These changes did not require additional

28
funding, education, or clinic time, but rather a reorganization of the day-to-day office
scheduling. Adapting the primary care setting so that CBT sessions were organized and had
sufficient time for consultations and therapy allowed for effective CBT delivery (Aschim et
al., 2011; Mignogna et al., 2018). Strategies for reorganization included: scheduling CBT
sessions for the last office hours on a particular day, blocking off certain time on certain days
of the week, and organizing support staff to prevent session interruptions (phone calls,
questions, etc.). Being able to deliver effective CBT interventions through practice
reorganization was viewed among the researchers as a contributing factor to improved
symptom outcomes in patients receiving CBT treatment (Aschim et al., 2011; Mignogna et
al., 2018).
The body of literature demonstrated that overall, CBT type interventions are
reasonable and achievable options for CNCP treatment in the primary care setting, especially
when settings are reorganized to facilitate CBT integration. By doing so, providers who are
not specifically trained in mental health interventions are set up for success in the provision
of CNCP management.
Primary Care Providers.
A variety of different providers supply healthcare within the primary care setting.
Given the difference amongst each provider’s education and practice focus, skills, and
competencies, it was important to evaluate which primary care providers delivered the
CBT/bCBT type interventions.
Cognitive Behavioral Therapy interventions were delivered by GPs (Aschim et al.,
2011; Mathieson et al., 2013; Dorflinger et al., 2016; Hoifodt et al., 2011); primary
healthcare therapists, which included counselors and behavioral health therapists who

29
worked in primary care settings (Lewis, 2013; Funderburk et al., 2011); NPs (Buysse et al.,
2011; Jungquist et al., 2010; Broderick et al., 2014) and a variety of providers who were
described as: social workers, psychiatrists, and psychologists (Mignogna et al., 2018; Knoerl
et al., 2015; Richmond et al., 2015).
While the components of the CBT interventions differed amongst all the studies,
seven studies demonstrated that CBT interventions delivered by GPs had effective outcomes
among the patients (Aschim et al., 2011; Mathieson et al., 2013; Hoifodt et al., 2011;
Richmond et al., 2015; Knoerl et al., 2015; Dorflinger et al., 2016; Mignogna et al., 2018). In
the longitudinal cross-sectional study by Aschim et al (2011) 68 General Practitioners
underwent CBT course training to provide CBT interventions in their primary care clinics.
By doing so, GPs increased patient engagement in CBT activities and improved outcomes in
patient depression and anxiety symptoms. The authors concluded that these GPs effectively
delivered CBT interventions (Aschim et al., 2011). Mathieson et al (2013) further built upon
the study by Aschim et al (2011) by completing a case control study, whereby a CBT manual
was developed for GPs to facilitate treatment delivery for patients with anxiety and
depression. Mathieson et al (2013) found that with the assistance of CBT manuals (but no
formal CBT course) GPs were still able to successfully deliver CBT interventions, thereby
improving patient depression and anxiety symptoms.
In an integrative literature review by Knoerl et al (2015), in which thirty-five RCT
were reviewed, researchers found that provider (including GPs) delivered CBT interventions
improved pain intensity in 43% of their study sample. Forty-three percent of the studies
within this review illustrated that providers from a variety of professional, educational, and
skills backgrounds can effectively provide CBT to CNCP patients, rather those patients

30
having to receive CBT treatment solely from a provider specialized in CBT interventions.
Two studies built on the work by Knoerl et al (2015) by comparing provider (including GPs)
delivered CBT to the usual care and found that when compared to the usual care (exercise &
pharmacotherapeutics) provider delivered CBT interventions produced greater positive
patient outcomes in their depression and pain (Mignogna et al., 2018; Richmond et al., 2015).
A meta-analytic systematic review by Hoifodt et al (2011) found differently from Mignogna
et al (2018) and Richmond et al (2015) in that training PCPs to deliver CBT did not enhance
effects relative to usual treatment in their study. Though PCP delivered CBT interventions
was no more effective than the usual care within this particular study, PCP delivered CBT
interventions was still identified an efficacious treatment (Hoifodt et al., 2011).
The article with mixed findings concerning the efficacy of PCP delivered CBT was
the systematic review without meta-analysis by Dorflinger et al (2016). Dorflinger et al
(2016) found that few studies existed concerning outcomes following PCP delivered CBT
interventions and those studies that did exist had mixed findings. Researchers felt the mixed
findings were as a result of variability in the studies sample sizes, methodologies, training
content and design, and assessment of outcomes (Dorflinger et al., 2016). The authors of this
study did identify gaps in the literature concerning outcomes related to PCP delivered bCBT
and was included in this review to illustrate these gaps.
Given that an overlap in scope of practice that exists between NPs and GPs who work
in primary care settings, it is necessary to illustrate that the findings pertaining to GPs within
this review also apply to NPs who practice in primary care settings (American Associate of
Nurse Practitioners, 2015). Positive symptom outcomes were identified in three randomized
control trials, where NPs delivered CBT interventions in PC settings to patients with

31
insomnia, and co-occurring CNCP and insomnia (Broderick et al., 2014; Buysse et al., 2011;
Junquist et al., 2010). In particular, two studies found that in the primary care setting, NP
delivered CBT interventions for insomnia (CBT-I) produced notable improvements in sleep
continuance, thereby significantly reducing the patient’s insomnia (Buysse et al., 2011;
Junquist et al., 2010). Junquist et al (2010) further evaluated the effect of CBT-I on chronic
pain outcomes, given the co-occurrence of insomnia and CNCP. Participants within this
study, who were double match randomized by a third party, described NP delivered CBT-I as
having significantly reduced their pain interference and improved sleep continuance
(Junquist et al., 2010).
Buysse et al (2011) built upon the study by Junquist et al (2010) by analyzing the
efficacy of CBT-I interventions longitudinally and found that a remission in insomnia
symptoms was maintained at 6 months post CBT-I. Similarly, Broderick et al (2014)
evaluated longitudinal maintenance of outcomes within their RCT, but elaborated on the
abilities of CBT longitudinal maintenance in patients with chronic osteoarthritic pain.
Broderick et al (2014) found that NPs were able to provide improvements in fatigue, social
functioning, health satisfaction, and decreased use of pain medication by providing CBT
interventions up to 12 months post interventions (Broderick et al., 2013).
Two studies found that CBT type interventions delivered by primary healthcare
therapists led to improved outcomes in patients with medically unexplained pain symptoms
(MUS) and those with depression (Lewis, 2013; Funderburk et al., 2011). These providers
were often described within the body of literature as having specific knowledge and skills to
provide CBT interventions, making them the most appropriate provider to deliver these
interventions. However, findings from these two studies showed that primary healthcare

32
therapists who were described as being master level trained professionals in specific
counseling and mental health services like CBT, encountered challenges and knowledge gaps
when providing education and counseling concerning biomedical aspects of the patient’s
condition (Lewis, 2013; Funderburk et al., 2011).
In the cross-sectional study by Lewis (2013), eight primary healthcare therapists
provided CBT interventions to patients with MUS. Of note, providers articulated that they
had significant limitations in their knowledge, skills, and abilities to provide appropriate
advice, guidance, and recommendations surrounding topics and patient concerns related to
the biomedical aspects of the condition. Funderburk et al (2011) conducted a case-control
study to evaluate a sample of 180 charts of patients who received CBT type interventions by
primary healthcare therapists. The researchers noted that primary healthcare therapists, who
were non-prescribers, had difficulties offering education regarding new prescriptions and
or/discussing medication adherence, as these skills were identified as outside their
competencies as non-prescribing primary healthcare therapists (Funderburk et al., 2011).
Based on the findings, primary healthcare therapists are limited in their ability to provide
biomedical treatment. The findings illustrate that it is more feasible for NPs and other PCPs
to integrate CBT interventions into practice than for primary healthcare therapists to integrate
biomedical knowledge into their practice.
This body of literature demonstrated that overall, primary health care providers who
are not specifically trained in mental health interventions can effectively deliver CBT
interventions within the primary care setting. It was therefore important to evaluate the body
of literature to identify the facilitators and barriers that exist for primary care providers
integrating CBT interventions into their primary care practices.

33
Effective Cognitive Behavioral Therapy Interventions: Facilitators and Barriers
Facilitators that improved CBT efficacy and barriers to intervention success emerged
as the second theme from the literature. Seven of the twelve articles included in this review
evaluated the effectiveness of specific facilitators for CBT intervention success (Jungquist, et
al., 2011; Mignogna et al., 2018; Aschim et al., 2011; Funderburk et al., 2011; Broderick et
al., 2014; Buysse et al., 2011; Hoifodt et al., 2011). Likewise, seven of the twelve studies
analyzed aspects that acted as barriers to CBT intervention success. This theme was explored
to demonstrate which strategies amongst the studies promoted bCBT uptake and achieved
improvements in patient outcomes. It was also important to show those barriers that arise
with bCBT delivery and the available strategies to mitigate those barriers. Four subthemes
emerged from this second finding: CBT manual resource, adapting therapy and engaging
patients, workbooks and home activities, and brief type interventions. These four subthemes
are discussed further below.
Cognitive Behavioral Therapy Manual Resource.
Five of the seven studies demonstrated that bCBT interventions were more easily
employed and effective with the use of a CBT practice manual (Mignogna et al., 2018;
Funderburk et al., 2011; Broderick et al., 2014; Mathieson et al., 2013; Jungquist et al.,
2011). Through these manuals providers were guided with an accessible standardized
treatment resource tool. Manuals that were adaptable and offered choices for specific
interventions and activities/exercises as it pertained to individual patients in particular
appointment type settings, facilitated bCBT delivery and encouraged providers to use the
manuals (Mignogna et al., 2018; Funderburk et al., 2011; Broderick et al., 2014; Mathieson
et al., 2013; Jungquist et al., 2011). Providers within the studies by Mignogna et al (2018),

34
Funderburk et al (2011), Broderick et al (2014), Mathieson et al (2013), and Jungquist et al
(2011) also noted that CBT manuals that were clear, had specific treatment focuses;
individualized exercises/activities; limited goals; a focus on present stress; rapid assessment;
and a high level of provider-patient interaction promoted effective bCBT delivery and
encouraged patient participation. By effectively delivering bCBT interventions, researchers
noted that patient outcomes were improved (Mignogna et al., 2018; Funderburk et al., 2011;
Broderick et al., 2014; Mathieson et al., 2013; Jungquist et al., 2011).
Adapting Therapy and Engaging Patients.
Adapting the interventions to meet the needs of the situation and patient was
identified as a facilitator to successful therapy delivery and patient engagement among four
of the seven studies (Mignogna et al., 2018; Funderburk et al., 2011; Broderick et al., 2014;
Mathieson et al., 2013). Adaptation of the interventions was described as: simplifying
language within the study’s CBT manual, learning how to better pace the content delivered
during sessions, and being flexible with manual interventions during sessions (Mignogna et
al., 2018; Funderburk et al., 2011; Broderick et al., 2014; Mathieson et al., 2013). In
particular, Mignogna et al (2018), Broderick et al (2014), and Mathieson et al (2013) noted
that being flexible with the manual by adjusting and choosing particular CBT manual
interventions helped promote provider uptake of the therapy and encouraged patient
engagement; this led to improve patient outcomes.
Funderburk et al (2011) and Mignogna et al (2018) found that modifying patient
assessments to involve patients in discussions regarding their symptoms and treatments was a
necessary component of therapy adaptation that led to patient engagement in subsequent
bCBT sessions. In particular, providers who inquired about the patient’s symptoms, thoughts,

35
and the behaviors that perpetuated pain; what strategies the patient had previously tried; and
those they wanted to try created sessions whereby patients felt heard and validated regarding
their condition. This promoted increased acceptance and adherence to subsequent bCBT
delivery. Initial provider-patient discussions led to providers being able to deliver a more
individualized approach to CBT intervention for their patients. A final adaptation of CBT
interventions that facilitated the therapy was engaging the patient face to face (Mignogna et
al., 2018). By doing so, providers were able to develop a therapeutic relationship with the
patient, making the patient more likely to be engaged in CBT (Mignogna et al., 2018).
Barriers to effective CBT adaptation were identified when providers failed to allot
specific amount of session time to address patient concerns not related to CBT interventions.
Appointment sessions that did not offer treatment activities to target patient concerns such as
relationships and finances led to patients going off topic, which led to reduced bCBT efficacy
(Mignogna et al., 2018; Funderburk et al., 2011). Barriers were mitigated by employing
closed ended questions to ascertain the nature of the concerns. Closed ended questions helped
triage patient issues not related to bCBT interventions so that bCBT sessions were not
interrupted, while still acknowledging the patient’s concerns and the need to address those
concerns at a subsequent appointment not designated for bCBT (Funderburk et al., 2011).
The findings illustrated that it is important for providers and patients to negotiate and
establish the terms of the bCBT session. Engaging in provider-patient discussions concerning
the purpose and goals for the sessions, can ensure homogenous expectations for treatment.
Workbooks and Home Activities.
Three of the seven studies described the use of CBT workbooks and home activities
as a facilitator that promoted effective bCBT (Mignogna et al., 2018; Hoifodt et al., 2011;

36
Broderick et al., 2014). In their study, Broderick et al (2014) found that assigning instruction
in a new coping skill, guided practice in that skill, and a home practice assignment was an
integral component of bCBT that set up for review and problem-solving strategies in the
subsequent sessions. Likewise, Buysse et al (2011) suggested that when provided with a
specific written prescription for CBT-I, patients were more likely to adhere to those
prescriptions, which translated to symptom improvements. Being able to reinforce the bCBT
at home was considered to be a significant finding.
A barrier to CBT workbooks and home activities existed when patients were asked to
complete homework to reinforce the skills, exercises, and activities learned during the
sessions (Mignogna et al., 2018). Patients described feeling that they were being asked to
complete ‘homework’ (Mignogna et al., 2018). This challenged provider’s abilities to deliver
effective bCBT. A strategy to overcome this barrier was described as setting the expectation
at the beginning of treatment that home type activities were important for treatment success,
and by referring to them as home activities rather than ‘homework’ (Mignogna et al., 2018).
Brief Type interventions.
A final subtheme was how CBT interventions were delivered. Five of the seven
studies found that interventions with a clear specific treatment focus and limited session
goals led to rapid assessment and promoted a high level of provider-patient activity
(Mathieson et al., 2013; Broderick et al., 2014; Mignogna et al., 2018; Buysse et al., 2011;
Junquist et al., 2010). Among four of those studies, both patients and providers felt that
though brief CBT sessions were short in duration (less than traditional 30 minutes), providers
were able to pare down session content and deliver salient interventions components
(Mathieson et al., 2013; Broderick et al., 2014; Mignogna et al., 2018; Junquist et al., 2010).

37
Focusing on a couple of teachable skills and a short review of content delivered in the last
session facilitated bCBT delivery and helped ensure that content was understood (Mathieson
et al., 2013; Broderick et al., 2014; Mignogna et al., 2018; Buysse et al., 2011; Junquist et al.,
2010).
Brief type interventions were completed and well tolerated in 92% of the participants
in the study by Buysse et al (2011). Though the interventions were described as brief, they
were achievable with small, time limited goals including: (1) reducing time in bed; (2)
getting up at the same time every day, regardless of sleep duration; (3) not going to bed
unless sleepy; and (4) not staying in bed unless asleep (Buysse et al., 2011). Likewise,
Broderick et al (2014) also found that NP delivered brief interventions were well tolerated in
their participants. Patients reported that short sessions focusing on 1-2 interventions were not
overwhelming making bCBT sessions approachable and that the 1-2 interventions were more
pertinent to their symptoms, which promoted their engagement in sessions. Mignogna et al
(2018) also found in their study that creating brief sessions was also beneficial for the
delivering provider. Brief CBT intervention delivery allowed the provider to maintain focus
on a particular manual module, thereby preventing them from becoming overwhelmed
(Mignogna et al., 2018). By having multiple bCBT sessions, Mignogna et al (2018) also
noted that patients had less content to recall from past and current sessions, which facilitated
bCBT intervention usage and improved their symptoms.
Use of specific resources/manuals, adaptation, and having brief and achievable
interventions can improve the efficacy of CBT intervention delivery. It is therefore necessary
to improve access to support resources/tools and training for providers in primary care to
promote adoption of bCBT interventions.

38
Cognitive Behavioral Therapy Education for Providers
The final theme within the literature was related to CBT knowledge and education for
primary care providers. The theme of PCP knowledge and education was broken down
further into educational opportunities that facilitated CBT use in PC and those that acted as
barriers. Six of twelve articles in this review found that education, support, and accessible
resources, led primary care providers to regularly employ CBT intervention (Aschim et al.,
2011; Broderick et al., 2014; Buysse et al., 2011; Jungquist et al., 2010; Mathieson et al.,
2013; Mignogna et al., 2018). These subthemes will be discussed below.
Education Facilitators and Barriers.
Four of the six articles found that education and having access to consultation
services with specialized mental health professionals facilitated the uptake of delivery of
CBT interventions by PCP in PC settings (Aschim et al., 2011; Broderick et al., 2014;
Mathieson et al., 2013; Junquist et al., 2010). Training/education sessions were described in
four articles as being broad and varied (see Literature Matrix), but helpful in developing
bCBT delivery confidence (Aschim et al., 2011; Broderick et al., 2014; Mathieson et al.,
2013; Junquist et al., 2010). Despite being broad and varied, all four studies noted
completion of training/education session as then being followed with access to consultations
with specialized mental health providers. Primary care providers submitted videos
performing CBT sessions with patients for detailed feedback from specialized mental health
providers, and were able to consult with the specialized mental health providers for direction
when concerns or guidance was needed regarding CBT delivery (Aschim et al., 2011;
Broderick et al., 2014; Mathieson et al., 2013; Junquist et al., 2010). All four of the studies
identified that having had CBT course training and having access to consultations with

39
specialized mental health providers as a facilitator that promoted the provider’s confidence in
providing bCBT interventions (Aschim et al., 2011; Broderick et al., 2014; Mathieson et al.,
2013; Junquist et al., 2010).
Mathieson et al (2013) also identified that an important facilitator to the uptake of
bCBT delivery by PCPs was for providers to self-reflect on misconceptions surrounding
bCBT. In particular, participants noted a strong feeling of bCBT interventions being strictly
specific to mental health settings and only provided by specific mental health providers
(Mathieson et al., 2013). Misconceptions also existed in that for PCPs to provide bCBT,
substantial additional education/training was required. In depth discussions between the
providers and the instructors were required for providers to “let go” of those misconceptions
(Mathieson et al., 2013). Once the providers were able to reconceive these beliefs they felt
more open to learning and delivering CBT type interventions in their own practice
(Mathieson et al., 2013).
Aschim et al (2011) alone described barriers to primary care provider delivery of
CBT interventions in the context of primary care. Aschim et al (2011) identified certain
barriers to uptake of CBT by PCP in PC settings included: the large amount of time to master
CBT interventions; the constraints of attending training/supervision during and after clinic
hours; having difficulties with changing clinic working style and scheduling, and a lack of
educational incentives to attend CBT education/training seminars. Providers were more
likely to employ CBT interventions when facilitators were present, while the presence of
barriers reduced motivation and incentive to use CBT interventions (Aschim et al., 2011).
To summarize, this analysis has provided a critical review of common themes within
the literature gathered on current use of Cognitive Behavioral Therapy interventions for

40
chronic non-cancer pain by Nurse Practitioners/Primary Care Providers within primary care
settings. In consideration of the research question, this analysis considers the factors
influencing PCP usage of CBT interventions in primary settings, training facilitators and
barriers of CBT, and outcomes of patients with CNCP. The next chapter provides a
discussion of these findings. It includes recommendations for clinical practice, implications
for NP practice, and limitations and recommendations for future research.

41
Chapter Five: Discussion
Through this integrative literature review process, I have been guided by the
following question “Would the integration of bCBT interventions by Nurse Practitioners
(NPs), into their primary care practices, improve function in adults with CNCP?” To answer
this research question, I completed a literature search that identified 12 applicable articles for
inclusion in this review, whose findings I analyzed in the previous chapter.
Three key findings were identified within the literature analysis to answer the
research question and included: provider and setting, effective Cognitive Behavioral Therapy
(CBT) interventions, and CBT education for primary care providers. In keeping with the
integrative literature review process, this chapter will focus on the synthesis of these key
findings from the literature analysis. I will then illustrate how the synthesis of the findings
led to the development of recommendations for primary care providers, in particular for
Nurse Practitioners, integrating brief CBT (bCBT) interventions into their practices.
Following the recommendations, I will discuss the limitations to this integrative literature
review and provide direction for future research.
Provider and Setting
Though short in nature, bCBT interventions are an achievable and applicable
treatment option for CNCP within primary care settings. However, misconceptions exist
regarding a primary care provider’s ability to deliver even condensed versions of CBT within
a primary care context (Mathieson et al., 2013). These misconceptions contribute to
hesitations for integration of bCBT interventions into primary care practices by primary care
providers (Mathieson et al., 2013).

42
Analysis of this body of literature has demonstrated that overall bCBT type
interventions are a reasonable and achievable option for CNCP treatment in the primary care
setting, especially when settings are reorganized to facilitate bCBT integration (Aschim et
al., 2011; Broderick et al., 2014; Buysse et al., 2011; Knoerl et al., 2015; Richmond et al.,
2015; Hoifodt et al., 2011; Junquist et al., 2010; Mathieson et al., 2013; Mignogna et al.,
2018; Lewis, 2013; Funderburk et al., 2011). By doing so, providers who are not specifically
trained in mental health interventions are set up for success in the provision of CNCP
management.
Setting.
The first finding that emerged from the literature analysis was related to the setting.
In particular, several studies within this review found that bCBT intervention success was not
dependent on the setting where the interventions were delivered, but rather the way that the
practice setting was organized or reorganized to facilitate effective bCBT intervention
delivery (Mignogna et al., 2018; Aschim et al., 2011).
According to Aschim et al (2011) changes to practice setting for bCBT delivery does
not require additional funding, education, or clinic time but rather a reorganization of the
day-to-day office scheduling. Reorganizing the primary care (PC) setting so that adequate
time is scheduled for bCBT sessions can facilitate bCBT integration. Reorganizing practice
settings could include even the simplest changes to scheduling routines such as: scheduling
bCBT sessions for the last office hours on a particular day, blocking off certain time on
certain days of the week, or noting in the schedule which appointments are assigned for
bCBT sessions (Aschim et al., 2011). By reorganizing practice settings, providers are less
likely to be overwhelmed during regular practice days to integrate bCBT sessions or during

43
the sessions themselves (Aschim et al., 2011; Mignogna et al., 2018). This consideration is
especially important for providers new to bCBT intervention delivery. Practice settings
reorganized for bCBT sessions allow new providers to hone skills and gain confidence in
those interventions without being overwhelmed by schedules or time.
Reorganizing practice settings can also facilitate provider and patient preparation for
bCBT sessions (Mignogna et al., 2018). Being aware of upcoming bCBT session days and
appointments allows opportunities for providers to prepare for those sessions, reducing the
work burden associated with having to deliver bCBT (Mignogna et al., 2018). Patients would
also be able to come prepared by knowing ahead of time that their specific day/appointment
is for bCBT. This helps mitigate those concerns not related to bCBT, and also provides
reassurance to patients with CNCP knowing that pain treatment is accessible. Practice
settings reorganized for bCBT sessions also help establish a practice routine whereby
interruptions such as phone calls, patient walk-ins, or patient fit-ins are discouraged as time
allotted for CBT sessions days/appointments are for CBT sessions alone (Aschim et al.,
2011; Mignogna et al., 2018).
By first performing a practice analysis to evaluate if the practice is indeed capable of
integrating specific bCBT session days, providers are able to also evaluate if barriers to
appointment access will arise for those patients not needing bCBT. If reorganization of
practice is not possible within a practice setting, providers should be cognizant that bCBT
interventions are still deliverable in non-bCBT designated appointments (Mathieson et al.,
2013; Broderick et al., 2014; Mignogna et al., 2018; Buysse et al., 2011; Junquist et al.,
2010).

44
Though bCBT sessions are short in duration (less than traditional 30 minutes),
providers are able to pare down session content and deliver salient CBT components in even
the briefest of primary care appointments. For example, by focusing on a couple teachable
skills and providing a short review of content delivered in the last session, bCBT intervention
delivery is facilitated during short appointment times (Mathieson et al., 2013; Broderick et
al., 2014; Mignogna et al., 2018; Buysse et al., 2011; Junquist et al., 2010). Likewise, setting
aside 5 minutes in the appointment to provide 1-2 bCBT interventions or to review
previously delivered interventions can exert meaningful changes in symptom outcomes
among patients with CNCP (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012;
Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018).
Primary Care Providers.
The type of primary care provider was another finding that emerged from the
literature analysis. All providers within this body of literature were able to successfully
deliver bCBT to patients (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2011;
Knoerl et al., 2015; Richmond et al., 2015; Hoifodt et al., 2011; Junquist et al., 2010;
Mathieson et al., 2013; Mignogna et al., 2018; Lewis, 2013; Funderburk et al., 2011). It
appears that the ability of the primary care provider to deliver effective bCBT is not solely
dependent on their role within primary care, but is dependent on their access and application
of appropriate tools, education, and support (Aschim et al., 2011; Broderick et al., 2014;
Buysse et al., 2011; Knoerl et al., 2015; Richmond et al., 2015; Hoifodt et al., 2011; Junquist
et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018; Lewis, 2013; Funderburk et al.,
2011). The differences among each primary care providers ability to offer whole person
CNCP care and their ability to provide treatment with both pharmacotherapeutics and non-

45
pharmacotherapeutics contributes to improved outcomes, and thus, function in patients
(Funderburk et al., 2011; Lewis, 2013).
Given their training and knowledge, primary healthcare therapists possess the
competencies as mental health providers to successfully deliver bCBT interventions and did
so among several of the studies (Funderburk et al., 2011; Lewis, 2013). What was significant
regarding their role as primary healthcare therapists, was the limitations they had within their
knowledge and skills to provide appropriate advice, guidance, and recommendations
surrounding patient concerns related to the biomedical aspects of their conditions (Lewis,
2013; Funderburk et al., 2011). These providers also noted difficulties offering education
regarding new prescriptions and/or discussing medication adherence, as these skills were
identified outside their competencies as non-prescribing primary healthcare therapists
(Funderburk et al., 2011; Lewis, 2013). While being able to provide bCBT interventions is
important to addressing the whole person, it is often only one component of CNCP care.
Many patients will require an integrated approach to also include pharmacotherapeutics
(Mills et al., 2016). Being unable to provide education regarding pharmacotherapeutics, let
alone prescribe them, creates barriers for patients seeking whole person CNCP care (Lewis,
2013; Funderburk et al., 2011). Likewise, patients with CNCP need to be engaged in an
integrated approach involving counseling, education, and assessment concerning their
physical, psychosocial, and functional symptoms. Without doing so, CNCP patients are left
with incomplete treatment, which may perpetuate their pain and reduce their function.
With the ability to engage patients in assessments, order diagnostic investigations,
diagnose medical conditions, and prescribe pharmacological and non-pharmacological
treatments as part of regular healthcare for CNCP, Nurse Practitioners (NPs) offer a variety

46
of options for whole person CNCP care (Aschim et al., 2011; Mathieson et al., 2013; Hoifodt
et al., 2011; Richmond et al., 2015; Knoerl et al., 2015; Dorflinger et al., 2016; Mignogna et
al., 2018; Broderick et al., 2014; Buysse et al., 2011; Junquist et al., 2010). Nurse
Practitioners also have much foundational knowledge related to CBT itself (CRNBC, 2016).
In other words, NPs as primary care providers have the foundation on which bCBT
intervention skills can build upon and can apply this therapy in practice to provide CNCP
patients with complete care.
Several studies within this literature review found that NPs were able to effectively
deliver bCBT interventions to patients with CNCP and/or insomnia, with all patients
reporting positive and successful outcomes in their symptoms and function following their
sessions with the NP (Broderick et al., 2014; Buysse et al., 2011; Junquist et al., 2010). Nurse
Practitioner delivered CBT interventions also provided improved longitudinal outcomes
(Broderick et al., 2014; Buysse et al., 2011). Considering these findings, it is clear that NPs
are not only able to engage patients in bCBT interventions, but they are also able to establish
longitudinal therapeutic relationships with their patients.
The body of literature illustrated that overall that bCBT interventions are reasonable
and achievable options for CNCP treatment in the primary care setting, especially when
settings are assessed to facilitate bCBT integration. By doing so providers who are not
specifically trained in mental health interventions are set up for success.
Effective Cognitive Behavioral Therapy Interventions: Facilitators and Barriers
The second finding that emerged from the literature analysis centered on the
facilitators and barriers to effective bCBT delivery in primary care settings. When bCBT
interventions are effectively delivered in primary care settings, patients are more likely to

47
have improvements in symptoms, thereby increasing their function (Aschim et al., 2011;
Broderick et al., 2014; Buysse et al., 2012; Jungquist et al., 2010; Mathieson et al., 2013;
Mignogna et al., 2018). Effective delivery of bCBT occurs with the presence of facilitators
while the presence of barriers can lead to decreased patient engagement, attendance, and
adherence to bCBT (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012;
Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018). Barriers also have
overall poorer patient outcomes (Aschim et al., 2011; Broderick et al., 2014; Buysse et al.,
2012; Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018).
Cognitive Behavioral Therapy Manual Resource.
The use of CBT manuals was described among much of the literature as being a
consistent strategy that facilitated the uptake of bCBT interventions in the primary care
setting (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012; Jungquist et al.,
2010; Mathieson et al., 2013; Mignogna et al., 2018). The use of these manuals gives users a
stepped approach to teaching, planning, and supporting patients through interventions. An
example of a CBT manual that is available to Canadian primary care providers is The
Cognitive Behavioral Interpersonal Skills Manual (CBIS Manual) (GPSC, 2015). Education
for use of The CBIS manual is also available to primary care providers to help facilitate the
manual’s integration into their practice. This manual is divided into modules that include:
assessment, education, activation, cognition, relaxation, anxiety, and lifestyle. It allows
providers to choose the most salient aspects of CBT that are applicable to the patient
complaint when time necessitates brevity (GPSC, 2015). The CBIS manual is also available
in a variety of languages and has a version for Indigenous populations (GPSC, 2015).
The CBT manual provides PCPs with a resource to refer to when questions

48
concerning delivery arise (GPSC, 2015). The manual provides a standardized manner in
which the interventions are delivered and are based upon recognized components of fulllength CBT interventions (GPSC, 2015). Employing CBT manuals helps encourage primary
care provider usage of bCBT interventions given the manual’s approachability, applicability
and ease for use in time limited settings like primary care (GPSC, 2015).
Adapting Therapy & Engaging Patients.
A consistent facilitator to the uptake of bCBT interventions in the primary care
setting is the employment of CBT practice manuals (Aschim et al., 2011; Broderick et al.,
2014; Buysse et al., 2012; Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al.,
2018). Specifically, being able to adapt the CBT manual to meet the needs of the situation,
patient, and provider helps facilitate effective bCBT delivery (Aschim et al., 2011; Broderick
et al., 2014; Buysse et al., 2012; Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et
al., 2018). Additional adaptations to the CBT manuals that facilitates effective bCBT is
simplifying CBT manual language and pacing the manual interventions based on patient
needs (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012; Jungquist et al., 2010;
Mathieson et al., 2013; Mignogna et al., 2018).
Cognitive Behavioral Therapy manuals that utilize simple language or allow primary
care providers to simplify terms and sentences within the manual are an important adaptation
for bCBT delivery (Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012; Jungquist
et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018). Comprehending bCBT terms and
jargon can contribute to confusion and may lead to patient disengagement (Mignogna et al.,
2018; Mathieson et al., 2013). It is therefore important for providers to employ CBT manuals
that are created for public usage so that they are at an appropriate reading/comprehension

49
level. Doing so can ensure that providers and patients have the same understanding and
interpretation of bCBT language and terms. Cognitive Behavioral Therapy manuals that
allow providers to deliver interventions in their own words can also help reduce patientprovider confusion while maintaining provider and patient engagement during bCBT
sessions (Mignogna et al., 2018; Mathieson et al., 2013). Primary care providers should
perform regular check-ins with patients to ensure that content is being understood and that it
is being delivered at an appropriate pace.
Another way to adapt the CBT manual for effective bCBT delivery is to pace the
interventions based on the patient’s needs (Aschim et al., 2011; Broderick et al., 2014;
Buysse et al., 2012; Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018).
Providers who are able to pace the bCBT session to meet the needs of the patient have
enhanced patient engagement and attendance in bCBT sessions, which can improve symptom
outcomes and function (Broderick et al., 2014; Buysse et al., 2012; Jungquist et al., 2010).
Recall that patients with CNCP experience daily pain; this may limit their ability to attend
even the briefest of CBT sessions or to attend sessions regularly (Mills et al., 2016). It is
necessary that providers and patients engage in discussions concerning expectations, goals,
and plans for bCBT sessions to develop strategies for pacing sessions that are feasible
(Mignogna et al., 2018).
A barrier to effective bCBT adaptation is not allotting a portion of session time to
address concerns outside the bCBT sessions (Mignogna et al., 2018; Funderburk et al., 2011).
In particular, bCBT sessions that do not allow treatment time to focus patient concerns that
are not related to bCBT can lead to patients going off topic or becoming unengaged in bCBT
interventions (Mignogna et al., 2018; Funderburk et al., 2011). It is therefore important for

50
providers to mitigate patient concerns not related to bCBT sessions. This can be done by
negotiating the bCBT sessions at the start and during subsequent sessions. Negotiating the
session could include establishing the purpose of the sessions, the goals of the patient for
sessions, and determining an action plan for each session (Stewart & DeNisco, 2019).
Acknowledging the person’s concerns regarding their other symptoms is necessary and
providers should book follow-up appointments to discuss those concerns.
Home Activities.
To ensure that session content is cemented and for patients to continue to build bCBT
skills, it is important to encourage bCBT intervention home activities (Mignogna et al., 2018;
Hoifodt et al., 2011; Broderick et al., 2014; Buysse et al., 2011). The use of bCBT
intervention home activities is as a facilitator that promotes effective bCBT delivery
(Mignogna et al., 2018; Hoifodt et al., 2011; Broderick et al., 2014). Brief Cognitive
Behavioral Therapy interventions are treatment approaches that teach patients skills to
become their own therapist over time (Mignogna et al., 2018). Patients learn new skills in the
therapy sessions, but ultimately much of the change occurs between sessions when patients
practice the skills in their own home environment. Home activities do not have to be lengthy;
providing one simple intervention at the end of an appointment for patients to practice at
home can still have effective outcomes (Mignogna et al., 2018). In their study, Broderick et
al (2014) found that assigning home activities including instruction in a new coping skill,
guided practice in that skill, and having patients practice assigned activities at home was an
integral component of CBT intervention success. Likewise, providing patients with a specific
written prescription for CBT interventions can help patients adhere to those prescriptions and
skills, which according to the research translates to symptom and function improvements

51
(Buysse et al., 2011).
It is important to note that a barrier to bCBT home activities exists. When patients are
asked to complete home activities to reinforce the skills, exercises, and activities learned
during bCBT sessions, patients may perceive that they are being asked to complete
‘homework’ (Mignogna et al., 2018). A strategy to overcome this barrier is setting the
expectation at the beginning of treatment that home activities are important for bCBT
intervention success and to refer to them as home activities rather than ‘homework’
(Mignogna et al., 2018; Hoifodt et al., 2011; Broderick et al., 2014; Buysse et al., 2011). The
more a patient practices these activities, the more of a habit they will become (Broderick et
al., 2014). Patients who participate in home activities will tend to hold on to their progress
over time; this helps make patients adequately prepared for independent bCBT intervention
usage (Broderick et al., 2014).
Adaptation, engagement, and the use of specific resources/manuals improves the
efficacy of CBT intervention delivery. It is therefore necessary to improve access to
resources and tools for primary care providers to promote adoption of CBT interventions.
Cognitive Behavioral Therapy Education for Providers
The final finding that emerged from the analysis surrounded the CBT education and
consultation support that promoted primary care provider confidence with bCBT delivery. A
common misconception identified among several studies indicated that being able to achieve
what providers perceived as confidence in bCBT delivery skills, required lengthy education
and training for those providers not specialized in mental health intervention training
(Aschim et al., 2011; Broderick et al., 2014; Mathieson et al., 2013; Junquist et al., 2010).
However, with appropriate education and support in the form of consultation services,

52
primary care providers are able to effectively deliver bCBT within their practices (Aschim et
al., 2011; Broderick et al., 2014; Mathieson et al., 2013; Junquist et al., 2010).
Several studies found that primary care provider education for bCBT delivery is
varied and broad (Aschim et al., 2011; Broderick et al., 2014; Mathieson et al., 2013;
Junquist et al., 2010). Yet, in all four of these studies, all providers were able to effectively
deliver bCBT interventions to patients (Aschim et al., 2011; Broderick et al., 2014;
Mathieson et al., 2013; Junquist et al., 2010). This finding illustrates that the ability to deliver
bCBT may not be dependent on type or length of CBT education and training. What also
improved the provider’s perceived confidence with bCBT delivery was the PCP having
access to specialized mental health consultation services. Having access to these services
following their education/training provides PCPs with an opportunity to obtain detailed
feedback from the specialized mental health providers (Aschim et al., 2011; Broderick et al.,
2014; Mathieson et al., 2013; Junquist et al., 2010).
While being critiqued and reassured in one’s ability to provide therapy is important
for developing bCBT skills and confidence, it is important to note that consistent and regular
access to consultations services from specialized mental health professionals may be
challenging to obtain. Primary care providers who work in settings with limited access to
consultations with mental health professionals are challenged in their ability to obtain
feedback and guidance from these specialized professionals. Primary care providers therefore
need other resources and tools for support and guidance. Primary care providers can employ
tools to develop confidence and skills in bCBT delivery, like a CBT manual. Outcome tools
that help validate the efficacy of bCBT, like the Coping Strategies Questionnaire or the Brief
Pain Inventory at the start of bCBT intervention sessions, during treatment, and at the end of

53
treatment can also provide reassurance for providers in their ability to deliver bCBT
(Broderick et al., 2014). These tools can also illustrate when patients may need referral to
full-service CBT.
Brief Cognitive Behavioral Therapy is indeed feasible and effective in the primary
care setting by providers who are not trained in specific mental health interventions. Being
able to offer bCBT to treat CNCP ensures that a whole person approach to care is achieved.
The recommendations for clinical practice are summarized in Table 1.
Recommendations for Clinical Practice
Based upon the aforementioned findings, I have created a set of recommendations to
assist primary care practitioners, including NPs, in the delivery of bCBT for the treatment of
CNCP. These recommendations aim to facilitate the primary care provider’s ability to
integrate bCBT.

54
Table 1. Recommendations

Recommendations
Organizing/Reorganizing
Primary Care Practice
settings for CBT
Sessions

Barrier
• Reduces appointment
availability for other patients
not needing bCBT

Primary Care Providers
to integrate CBT
interventions into
Practice

• Primary healthcare therapists
have limited ability advise,
guide, and educate biomedical
topics/concerns. Many do not
have prescribing ability

Use of CBT Manuals

Adapt CBT manual and
sessions

• Failing to allot bCBT session
time to address concerns not
related to bCBT interventions

CBT Home Activities

• Referring to home activities
as ‘homework’

Education and Mental
Health Consultation
Access

• Access to consultation with
mental health specialists may
be challenging to obtain

Facilitator
Strategies for Implementation
Evidence
• Reorganize/organize practices • Schedule bCBT for last or a block
• (Mignogna et al., 2018);
with appointment time/days
office hours with clear labelling of
Aschim et al., 2011)
for bCBT
appointments
• Recognize not all practices
• Prepare with CBIS manual
Can accommodate sessions
• Prepare patients
• Employ facilitators for bCBT • Employ home activities PRN
• GPs & NPs scope overlap;
• Engage patients provide: counseling,
• (Aschim et al., 2011;
both have biomedical
education, and assessments for whole
Broderick et al., 2014;
knowledge and prescribing
person CNCP
Buysse et al., 2011;
ability
Knoerl et al., 2015;
• Develop & sustain therapeutic
Richmond et al., 2015;
relationships
Hoifodt et al., 2011;
• Provide biomedical treatments, i.e.
Junquist et al., 2010;
pharmacotherapeutics
Mathieson et al., 2013;
• Integrate non-pharmacotherapeutics i.e.
Mignogna et al., 2018).
bCBT
• Use of CBIS manuals
• Start with 1-2 bCBT interventions
• (Broderick et al., 2014;
Buysse et al., 2012;
• Gives users a stepped
• Utilize manual activities for home
Jungquist et al., 2010;
approach to teaching,
• Attend training for CBT manual
Mathieson et al., 2013;
planning, and supporting
• Choose manuals with clear & concise
Mignogna et al., 2018).
patients in bCBT
approach
• Adapt CBT manual to meet
• Simply CBT manual language
• (Aschim et al., 2011;
the needs of the situation,
Broderick et al., 2014;
• Pace the CBT manual interventions
patient, and provider
Buysse et al., 2012;
• Review of last session’s content
Jungquist et al., 2010;
• Negotiate sessions at the start • Establish purpose, goals, and action plan
Mathieson et al., 2013;
and ongoing during treatment
of the CBT sessions
Mignogna et al., 2018)
• Acknowledge concerns not related to
bCBT and book follow-up appointment
• Activities cement content &
• Home activities not lengthy
• (Aschim et al., 2011;
skills
Broderick et al., 2014;
• Provide guided practice in assigned home
Buysse et al., 2012;
• Helps address time constraints
activities
Jungquist et al., 2010;
in appointments
• Provide home activities handouts or
Mathieson et al., 2013;
• Home activities as “activities”
written prescriptions
Mignogna et al., 2018)
as needed for bCBT success
• Consistent available access to
• Use of brief CBT practice manuals
• (Aschim et al., 2011;
consultation with specialized
Broderick et al., 2014;
• Create bCBT tool box with resources
mental health providers
Mathieson et al., 2013;
• Employ tools like PHQ-9, GAD-7, and
Junquist et al., 2010).
BPI for feedback on bCBT effect

55
Limitations and Future Research
Combining the data for the purpose of this review was met with some limitations
during the literature review process. First, only studies written in the English language that
were available via databases were included in the research collection. Applicable studies that
were not available in the English language may have be excluded as a result. Second, the
evidence in the secondary studies of this literature review combined data from studies
conducted in the United States, Australia, New Zealand, the United Kingdom, and Norway.
The applicability of evidence from studies conducted outside of Canada must be considered
carefully, especially where healthcare systems differ in terms of access, cost, and
sociodemographics. Thirdly, this review evaluated a sample population that consisted largely
of adult Caucasian male and female patients. Many other patient populations also suffer from
CNCP and the associated sequalae, though these populations were not included given the
narrow focus of this paper. In particular, patient populations including: pediatric and older
adults, immigrants, students, and specific ethnic populations were not included.
In this review, the literature search was conducted by one author, which possibly
introduced publication bias or the omission of current relevant papers. In particular, I, as the
author of this review, have had lifelong experience with a family member suffering from
CNCP. Such experience may have introduced some bias in the interpretation of the literature
and the following conclusions. Despite this personal experience, I focused on unbiased
interpretation of primary sources as suggested by Whittemore and Knafl (2005).
While this review has illustrated that the use of CBT manuals can facilitate effective
bCBT delivery, the literature did not provide direction as to how CBT manuals are
implemented into primary care practices. Specifically, this review is limited in its findings to

56
provide primary care providers with information regarding how, when, and with which
CNCP patients and CBT manuals to use in the management of CNCP. Future research is
therefore needed concerning strategies for the implementation of CBT manuals by primary
care providers in primary care settings. Though the evidence in this paper upholds the
hypothesis, the idea that bCBT interventions alone are the solution to CNCP treatment is
limiting. Future research relating to CNCP patient outcomes in symptoms and function
following multimodal treatments from primary care providers, like Nurse Practitioners, is
needed. Finally, the evidence illustrates that access to consultation services with specialized
mental health professionals helps encourage provider confidence in bCBT delivery.
However, not all primary care providers will have easily accessible consultation services.
Future research is therefore needed to illustrate if the effects of using outcome measures like
the PHQ-9, GAD-7, and the BPI can help improve provider confidence in bCBT delivery
when access to consultation services is limited.
Conclusion
It is estimated that one in five Canadians suffer from CNCP (Schopflocher et al.,
2011). With an ability to influence the physical and psychosocial wellbeing of sufferers,
adequate and timely access to multimodal CNCP treatments like CBT is paramount.
However, access to providers specifically trained in mental health interventions like CBT is
limited. By offering bCBT within the primary care setting primary care providers like Nurse
Practitioners can improve gaps in CBT service access. Current guidelines for CNCP care are
limited in the support they provide for integrating bCBT in primary care. Without adequate
support from guidelines and resources, primary care providers will face challenges when
offering treatment options for CNCP treatment.

57
This integrative literature review synthesized recent evidence to answer the following
question “Would the integration of bCBT interventions by Nurse Practitioners (NPs), into
their primary care practices, improve function in adults with CNCP?” A comprehensive
search of the literature was undertaken and 12 studies were selected for this review. The
evidence from these 12 articles was critically appraised on the basis of the strengths of the
evidence, its relevance to the research question, and to the British Columbia healthcare
context. Key findings from this integrative review included: primary care provider and
setting, effective CBT intervention delivery, and education for primary care providers.
Based on this review bCBT can be successfully delivered within the primary care
setting. Success to effective bCBT delivery is not dependent on the setting where the
interventions are delivered, but rather the way that the practice setting is organized or
reorganized to facilitate effective bCBT delivery (Mignogna et al., 2018; Aschim et al.,
2011). Likewise, it was found that bCBT interventions can be successfully employed by
providers who do not have specific mental health intervention training (Aschim et al., 2011;
Broderick et al., 2014; Buysse et al., 2011; Knoerl et al., 2015; Richmond et al., 2015;
Hoifodt et al., 2011; Junquist et al., 2010; Mathieson et al., 2013; Mignogna et al., 2018;
Lewis, 2013; Funderburk et al., 2011). With an ability to engage patients in assessments,
order diagnostic investigations, diagnose medical conditions, and prescribe pharmacological
and non-pharmacological treatments as part of the regular healthcare for CNCP, NPs can
offer the whole person care experience that CNCP requires (Broderick et al., 2014; Buysse et
al., 2012; Jungquist et al., 2010).
Improvement of symptoms including depression, anxiety, insomnia, and/or pain can
be seen when bCBT interventions are effectively delivered, which according to this body of

58
literature was linked to improved patient function (Aschim et al., 2011; Broderick et al.,
2014; Buysse et al., 2012; Jungquist et al., 2010; Mathieson et al., 2013; Mignogna et al.,
2018). Effective delivery of bCBT occurs with the presence of facilitators while the presence
of barriers can lead to decreased patient engagement, attendance, and adherence to bCBT
(Aschim et al., 2011; Broderick et al., 2014; Buysse et al., 2012; Jungquist et al., 2010;
Mathieson et al., 2013; Mignogna et al., 2018). The availability of education and resources
that facilitate bCBT delivery can help promote provider skill and confidence with bCBT.
Likewise, when education/resources are supported with access to consultation services from
specialized mental health professionals, providers gain more perceived confidence and are
more likely to employ bCBT in practice (Aschim et al., 2011; Broderick et al., 2014;
Mathieson et al., 2013; Junquist et al., 2010).
Finally, in keeping with the integrative review process, recommendations for future
research to build upon were developed. The recommendations included the need for primary
care providers to continue to build their knowledge, follow clinical guidelines, practice this
paper’s recommendations, and lead by example. In conclusion, this review shows that Nurse
Practitioners who work in primary care settings have the capacity to facilitate delivery of
bCBT, thereby improving biopsychosocial and functional outcomes in patients with CNCP.

59
References
Aschim, B., Lundevall, S., Martinsen, e., & Frich, J. (2011). Physicians' experiences using
cognitive behavioural therapy in general practice: A qualitative study.
Scandinavian Journal of Primary Health Care 29, 176-182.
doi: 10.3109/02813432.2011.595582
American Association of Nurse Practitioners. (n.d.). Nurse Practitioners in Primary Care
(Rep.). Retrieved, from
https://www.aanp.org/images/documents/publications/primarycare.pdf
Baker, N. (2016). Using Cognitive Behavior Therapy and Mindfulness Techniques in the
management of Chronic Pain in primary care. Primary Care 43(2), 203-216. doi:
10.1016/j.pop.2016.01.001.
Blaine, D., Williams, C., Morrison, J., Wilson, A., & Mercer, S. (2013). Cognitive
Behavioural Therapy: Why primary care should have it all. British Journal of
General Practice 63(607), 103-104. doi: 10.3399/bjgp13X663235.
Blount, F.A., & Miller, B.F. (2009). Addressing the workforce crisis in integrated primary
care. Journal of Clinical Psychology in Medical Settings 16(1), 113-119. doi:
10.1007/s10880-008-9142-7
British Columbia Government News. (2018). Creating new opportunities for nurse
practitioners as part of team-based care system. Retrieved from
https://news.gov.bc.ca/releases/2018HLTH0034-000995
British Columbia Provincial Academic Detailing. (2013). Opioids in Chronic Non-Cancer
Pain: The Basics. Retrieved from
https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/provincial-academicdetailing-service/opioids-resources.pdf
Broderick, J. E., Keefe, F. J., Bruckenthal, P., Junghaenel, D. U., Schneider, S., Schwartz, J.
E., Gould, E. (2014). Nurse practitioners can effectively deliver pain coping skills
training to osteoarthritis patients with chronic pain: A randomized, controlled trial.
Pain 155(9), 1743-1754. doi:10.1016/j.pain.2014.05.024
Bruehl, S. (2015). Complex Regional Pain Syndrome. British Medical Journal, 350, 1-19.
doi: 10.1136/bmj.h2730
Bushnell, M.C., Ceko, M., & Low, L.A. (2013). Cognitive and emotional control of pain and
its disruption in chronic pain. Nature Reviews Neuroscience 14(7), 502-511. doi:
10.1038/nm3516.
Busse, J. (2017). The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain.
CMAJ, 1-15. doi: 10.1503/cmaj.170363.

60

Buysse, D.J., Germain, A., Moul, D.E., Franzen, P.L., Brar, L.K., Fletcher, M.E., Begley, A.,
Houck, P.R., Mazumdar, S., Reynolds, C.F., Monk, T.H. (2011). Efficacy of brief
behavioural treatment for chronic insomnia in older adults. Archives of internal
Medicine 171(10), 887-895. doi: 10.1001/archinternmed.2010.535.
Critical Appraisal Skills Programme (CASP). (2013). CASP checklists. Retrieved from
http://www.casp-uk.net/#!casp-tools-checklists/c18f8
Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P.,Miaskowski,
C. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130. doi: 10.1016/j.jpain.2008.10.008
Clair, E.S. (2018). Centre for Effective Practice: Management of Chronic Non-Cancer Pain.
Retrieved from https://cep.health/clinical-products/chronic-non-cancer-pain/
College of Registered Nurses of British Columbia. (2016). Scope of Practice for nurse
practitioners: Standards, Limits, and Conditions. Vancouver, BC: College of
Registered Nurses of British Columbia.
David, L. (2010). Using CBT in general practice: The 10-minute consultation (1st ed.).
Oxfordshire: Scion Publishing Ltd.
Dorflinger, L.M., Fortin, A.H., & Foran-Tuller, K.A. (2016). Training primary care
physicians in cognitive behavioral therapy: A review of the literature. Patient
Education Counseling 99(8), 1285-1292. doi: 10.1016/j.pec.2016.02.014.
Dureja, G.P., Iyer, R.N., Das, G., Ahdal, J., & Narang, P. (2017). Evidence and consensus
recommendations for the pharmacological management of pain in India. Journal of
Pain Research 10, 709-736. Retrieved from https://www.dovepress.com/evidenceand-consensus-recommendations-for-the-pharmacological-managem-peer-reviewedarticle-JPR
Ehde, D.M., Dillworth, T.M., & Turner, J.A. (2014). Cognitive-Behavioral Therapy for
individuals with chronic pain. American Psychologist 69(2), 153-166. doi:
10.1037/a0035747
Farmanara, N., Marchildon, G.P., Quesnel-Vallee, A. (2016). Incorporating Cognitive
Behavioural Therapy into a public health care system: Canada and England
compared. Health Reform Observer 4(2), 1-17. doi: https://doi.org/10.13162/hroors.v4i2.2661
Funderburk, J.S., Sugarman, D.E., Labbe, A.K., Rodrigues, A., Maisto, S.A., & Nelson, B.
(2011). Behavioral health interventions being implemented in VA primary care
system. Journal of Clinical Psychology Medical Settings 18(1), 22-9. doi:
10.1007/s10880-011-9230-y.

61

Gabay, T.M., & Ledet, D. (2017). Neurovascular Disease. In Cartwright C., Wallace D.
(Eds.), Nursing Care of the Pediatric Neurosurgery Patient (3rd ed., pp. 395-456).
Kansas City, KS: Springer International Publishing.
General Practice Services Committee. (2015). CBIS: Cognitive Behavioral Interpersonal
Skills Manual. Retrieved from
http://www.gpscbc.ca/sites/default/files/CBIS%20Manual-Electronic%20Copy%20%20v2%20Oct%2022,%202015.pdf
Gillespie, L.D., & Gillespie, W.J. (2003). Finding current evidence: Search strategies and
common databases. Clinical Orthopaedics and related research 413, 133-145.
doi: 10.1097/01.blo.0000079324.41006.dc
Greenlee, P.S. & Rice, C. (2013). Concept Mapping: Topic organization for literature
review. Retrieved from https://digitalcommons.olivet.edu/lsci_facp/14/
Huether, S. E., Rodway, G., DeFriez, C. (2014). Pain, temperature regulation, sleep and
sensory function In K. L. McCance & S. E. Huether (Eds.), Pathophysiology: The
biologic basis for disease in adults and children (7th ed., pp. 1290-1318). St. Louis,
MO: Elsevier Mosby.
Hoifodt, R.S., Strom, C., Kolstrup, N., Eisemann, M., & Waterloo, K. (2011). Effectiveness
of cognitive behavioural therapy in primary care: A review. Family Practice 28(5),
489-504. doi: 10.1093/fampra/cmr017
International Association for the Study of Pain. (2018). IASP Terminology. Retrieved from
https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
Jungquist, C.R., O’Brien, C., Matteson-Rusby, S., Smith, M.T., Pigeon, W.R., Xia, Y., Lu,
N., & Perlis, M.L. (2010). The efficacy of cognitive-behavioral therapy for insomnia
in patients with chronic pain. Sleep Medicine 11(3), 302-309. doi:
10.1016/j.sleep.2009.05.018.
Knoerl, R., Lavoie Smith, E.M., & Weisberg, J. (2015). Chronic pain and Cognitive
Behavioral Therapy: An Integrative Review. Western Journal of Nursing Research
38(5), 596-628. doi: 10.1177/0193945915615869.
Lalonde, L., Leroux-Lapointe, V., Choinere, M., Martin, E., Lussier, D., Berbiche, D.,
Lamarre, D., Thiffault, R., Jouine, G., & Perreault, S. (2014). Knowledge, attitudes
and beliefs about chronic non-cancer pain in primary care: A Canadian survey of
physicians and pharmacists. Pain Research and Management 19(5), 241-250.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197751/
Lewis, H. (2013). An exploratory study of primary-care therapists’ perceived competence in
providing cognitive behavioral therapy to people with medically unexplained

62
symptoms. The Cognitive Behaviour Therapist 6, 22-29. doi:
10.1017/S1754470X13000202
Lynch, M.E. (2011). The need for a Canadian pain strategy. Pain Research and Management
16(2), 77-80. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084407/
Manchikanti, L., Abdi, S., Atluri, S., Balog, C. C., Benyamin, R. M., Boswell, M. V., Wargo,
B. W. (2012). American Society of Interventional Pain Physicians (ASIPP)
guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2Guidance. Pain Physician, 15, S67-S116. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/22786449
Martini, F.H., Nath, J.L., & Bartholomew, E.F. (2015). Neural Tissue. In Fundamentals of
Anatomy & Physiology (10th ed. 388-507). Glenview, IL: Pearson Education, Inc.
Mathieson, F., Collings, S., Dowell, A., & Goodyear-Smith, F. (2013). Collaborative
research: A case example of dissemination of CBT in primary care. The Cognitive
Behaviour Therapist 6, 40-58. doi: 10.1017/S1754470X13000093
Melnyk, B.M. & Fineout-Overholt, E. (2015). "Box 1.3: Rating system for the hierarchy of
evidence for intervention/treatment questions" in Evidence-based practice in nursing
& healthcare: A guide to best practice (3rd ed.) (pp. 11). Philadelphia, PA:
Wolters Kluwer Health.
McGinn, L. K. (2000). Cognitive behavioral therapy of depression: Theory, treatment and
empirical status. American Journal of Psychotherapy, 54(2). Retrieved from
http://isites.harvard.edu/fs/docs/icb.topic474941.files/McGinnArticle-1.pdf.
McHugh, P., Gordon, M., & Byrne, M. (2014). Evaluating brief cognitive behavioural
therapy within primary care. Mental Health Review Journal 19(3), 196-206. doi:
10.1108/MHRJ-02-2014-0004
Mills, S., Torrance, N., & Smith, B.H. (2016). Identification and management of chronic pain
in primary care: A review. Current Psychiatry Reports 18, 22-22.
doi:10.1007/s11920-015-0659-9
Mignogna, J., Hundt, N.E., Kauth, M.R., Kunik, M.E., Sorocco, K.H., Naik, A.D., Stanley,
M.A., York, K.M., & Cully, J.A. (2014). Implementing brief cognitive behavioral
therapy in primary care: A pilot study. Translational Behavioral Medicine 4(2), 175183. doi: 10.1007/s13142-013-0248-6.
Mignogna, J., Martin, L. A., Hundt, N.E., Kauth, M., Naik, A.D., Sorocco, K., Benzer, J., &
Cully, J. (2018). “I had to somehow still be flexible”: Exploring adaptations during
implementation of brief cognitive behavioral therapy in primary care. Implementation
Science 13(76), 1-11. Retrieved from

63
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0768
Muldoon, L., Dahrouge, S., Russell, G., Hogg, W., & Ward., N. (2012). How many patients
should a family physician have? Factors to consider in answering a deceptively
simple question. Healthcare Policy 7(4), 24-34. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359082/
O'Kelly, M. (2010). CBT in action: A practitioner's toolkit (1st ed.). Melbourne, AU:
Graphic Partners Australia Pty Ltd.
Richmond, H., Hall., A.M., Copsey, B., Hansen, Z., Williamson, E., Hoxey-Thomas, N.,
Cooper, Z., & Lamb, S.E. (2015). The effectiveness of Cognitive Behavioural
Treatment for non-specific low back pain: A systematic review and meta-analysis.
PLoS One 10(8), Retrieved from
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0134192
Schopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada.
Pain Research Management, 16(6), 445-450. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/pdf/prm16445.pdf
Stewart, J. G., & DeNisco, S.M. (2019). Role development for Nurse Practitioners (2nd ed.).
Bellingham, MA: Jones & Barlett Learning, LLC.
Torraco, R. J. (2005). Writing integrative literature reviews: Guidelines and examples.
Human Resource Development Review 4(3), 356-367. Retrieved from
http://economywork.com/docs/Torraco2016HRHR.pdf
Weisberg, R.B. & Magidson, J.F. (2016). Integrating Cognitive Behavioral Therapy into
primary care settings. Cognitive Behavioural Practice 21(3), 247-251. doi:
10.1016/j.cbpra.2014.04.002
Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology.
Journal of Advanced Nursing, 52(5), 546-553. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2005.03621.x

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Appendix A

Chronic Non-Cancer Pain

Psychological
Impact

Physiological
Impact
Treatment Regimes

Non-Pharmacotherapeutics

Pharmacotherapeutics

bCBT

Others:
Physiotherapy,
Massage, Acupuncture

Facilitators

Sessions close to home, provider
support, realistic conversations
regarding regime, having
accessibility,

Can NPs
effectively deliver
bCBT?

Medications

Barriers

Specialist Shortage, Delayed
Access, Limited Accessibly.

Can bCBT be
effectively delivered
in primary care?

“Would the integration of brief CBT
interventions by Nurse Practitioners (NPs), into
their primary care practices, improve function in
adults with CNCP?”

Can bCBT be an
effective
treatment in
CNCP?

65
Appendix B

Literature search terms inputted into each database: (chronic pain* OR persistent pain* OR long
term pain* OR chronic non-cancer pain* OR depression* OR anxiety* OR insomnia*) AND (CBT
OR Cognitive Behavio?ral Therapy* OR Behavio?ral Therapy* OR Cognitive Therapy* OR Brief
Intervention Therapy* OR bCBT* OR CBT-I*) AND (Primary Care Provider* OR General
Practitioner* OR Nurse Practitioner*)

Google Scholar

Research identified
through database
searching
(n=15,900)

PubMed

Research identified
through database
searching
(n=1921)

PsychInfo &
PsychARTICLES

CINALH, CINALH with
full text & MEDLINE
(EBSCOhost)

Research identified
through database
searching
(n=236)

Research identified through
database searching
(n=515)

Total: (n=18, 572)

Those excluded based on exclusion
criteria (n= 18,042)

Potential studies retrieved for
detailed evaluation (n=517)

Duplicates: (n=18)

Those excluded by screening abstracts and
titles (n=487)

Total after duplicate exclusion: (n=499)

Selected studies included in systematic
review
(n= 12)

66
Appendix C
Article/Study Design & Overview

Aschim, B., et al. (2011)
Cross-sectional longitudinal
qualitative study exploring GP's
experiences using CBT, and what
factors promote or limit its use in
the primary care setting
Intervention: CBT course that
lasted nine months. Fifty hours
teaching and 15 hours
supervision. Presented video of
them performing CBT on patient
for feedback
Broderick, J.E., et al. (2014).
Randomized Control Trial
examining the effectiveness of
pain coping skills training for
patients with osteoarthritis
delivered by trained NP in
community primary care offices.
Intervention: Pain coping
strategy therapy. Four broad
coping skills were taught across
the ten 30- to 45-minute sessions:
relaxation response, attention
diversion techniques, altering
activity and rest patterns as a way
of increasing activity level, and
reducing negative pain- related
thoughts and emotions. The
sessions were outlined in detail in
a treatment manual

Strengths
Was a longitudinal study

Limitations
Participants self-selected sample of
GPs

Course completed was accredited CME.
Evaluated by certified CBT instructors and
psychologists.
Objective measures: video tapped focused
interviews with free text data comments.
Analysis according to principles of Giorgi’s
phenomenological analysis. Sound
description of analysis.

Randomized Control Trial with control
group
Sample (N= 256)

Sample smallGeneral Practitioners: (N=15)
Participants receiving CBT
(N=68)
Free text data quotes translated from
Norwegian to English.
Norwegian based; different health
system and potentially different GP
practice and views on CBT
Convenience sample- assessor
blinding compromised
Attrition 29% at 12-mos follow up
(no difference between groups)

Longitudinal Study
Small ES
Care delivery model using NP to deliver
PCST to CP populations, composites for
OC measures
NPs completed received an initial 2-day
training workshop in PCST. Continued
training with the instructors at their site to
reach competency. Competency determined
by specialized therapist based on study
established performance scale (1=poor,
5=excellent).
Objective Measures: AIMS2, BPI,
WOMAC, CSQ, BDI, BFI, IVR, quality of
life scale. Compared at base line, post
treatment, 6-month and 12-months post.
Sound statistical analysis

Results may not be generalizable to
other CP populations
NP provider (N=3)
US-based; different health system and
potentially different NP
practice/education and views on CBT

Utility/Important Findings
Promoting: CBT usage in PC settings was structured
supervision and group counseling, receiving individual
feedback and being able to master therapeutic
techniques.
Limiting: length of time to master techniques,
difficulties finding eligible patients, constraints of time,
and lack of financial incentives to use CBT in practice
CASP= High

NP delivered PCST produced significant improvements
in a range of pain related variables the use of pain
medication compared to the usual care.
NP level of proficiency was not associated with level of
improvement that patient achieved, but most NPs in
study reached moderate to high level competence
CASP= High

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Article/Study Design & Overview

Buysse, D.J., et al. (2011)

Strengths
Randomized Control Trial

Limitations
Convenience sample- assessor
blinding compromised

Utility/Important Findings
Produced statistically and clinical meaningful
improvements that were sustained for six months.

Control condition that was not
matched for therapist time.

CASP= Moderate

Intervention effects followed longitudinally
RTC to evaluate the short-term
efficacy and 6-month durability
of nurse practitioner delivered
brief behavioral treatment for
insomnia (BBTI) vs an
information control (IC)
intervention among older adults
with insomnia
Intervention: BBTI, consisting of
individualized behavioral
instructions delivered in 2
intervention sessions and 2
telephone calls, or IC, consisting
of printed educational material.
Dorflinger, L.M., et al. (2016).

Convergent self-report, observer-rated and
physiologic outcomes
Sample that is generalizable to practice
settings (N=79)
Objective Measures: SES Ladder,
Charleston Comorbid Index, PSQI,
Epworth Sleepiness Scale, The Pittsburgh
Sleep Diary.

The use of a single NP for both
conditions (N=1)
US-based; different health system and
potentially different NP
practice/education and views on CBT

Sound statistical analysis
Strength in being a systematic review.

Small sample: (N=4) RCTs were
accepted for the final sample

Two studies noted increased frequency of skill use
through assessment of PCP case notes.

Studies included highly variable

Significant increase in both self-reported knowledge
and skills, though two studies found no significant
difference in knowledge between pre and post training.

Systematic Review to review the
literature on CBT training
programs for PCPs, and describe
the structure, content, and
outcomes of identified studies of
which included pre-post and RCT
designs.

Samples provided variation in adult age,
gender, and condition being treated.
Recruited from a variety of settings. Good
generalizability.
Selected PCP from variety of settings
including NPs

Outcomes of patients who received
CBT were mixed.

Funderburk, J.S., et al (2011).

Review patient charts of PC participants
evaluating demographics, session details
such as intervention.

Sample of providers delivering
interventions (N=9)

Case-control study to explore
what types of problems
Behavioral Health Providers are
treating and what types of
clinical interventions they are
using in PC.
Intervention: A chart review was
conducted of patients (N = 180)
seen by BHPs in five primary
care clinics to evaluate which
common interventions were used:

Sample participants receiving therapy (N180)
Objective Measures: Charts were reviewed
by two advanced clinical psychology
doctoral students and one clinical
psychologist and all had clinical experience
within integrated primary care settings.
To establish inter-rater reliability, records

Two studies found an increase in reported use of CBT
assessment and intervention following training.

Providers had some training in
behavioral treatment therapy
US-based; different health system and
potentially different NP
practice/education and views on CBT

CASP= High
BHPs provided treatment to patients with mental health
concerns to health psychology interventions for things
like pain management.
Most common diagnosis seen was depression and
anxiety.
Prescribing BHP most likely to use medical
management.
Visits for cognitive and behavioral therapy lengthy than
visits in mental health clinics- likely related to the brief
nature of visit. Most patients likely to only attend one
session, which averaged 41.9 mins. During initial visits

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Article/Study Design & Overview

medical management, psychoeducation, elements of cognitivebehavioral therapy (CBT), and
supportive psycho- therapy.

Strengths
were randomly selected using a random
numbers table, and raters were compared

Limitations

Utility/Important Findings
brief history and information of presenting problem
obtained- much like PCP methods.
CASP= High

Provided thorough review of charts and
noted provider characteristics in terms of
treatment choices, approaches and follow
ups
Hoifodt, R.S., et al (2011)
Systematic review of quantitative
literature on the effectiveness of
CBT for depression and anxiety
disorders delivered in primary
care by primary care therapists.

Moderate statistical analysis
Total studies included (N=17)
RCT Studies (N=13)

Evaluated effects of telephone
delivered CBT, face to face, or both.
Also included CBT +/antidepressants in assessment.

Natural groups design- longitudinal
Samples provided variation in adult age,
gender, and condition being treated.

Some patients in studies were
younger than 18 years- makes it
difficult to generalize to this ILR

Recruited from a variety of settings. Good
generalizability.
Jungquist, C.R., et al. (2010)
RCT to study 1) additional
evidence regarding the efficacy
of CBT-I in treating insomnia in
the context of chronic pain and 2)
assess whether CBT-I is
associated with clinical changes
with respect to pain severity
and/or pain interference
Intervention: The eight weekly
session protocol adhered to the
regimen specified in our
published treatment manual and
included 4 central components:
Sleep Restriction Therapy,
Stimulus Control Instructions,
Sleep Hygiene Instructions, and
one session of cognitive therapy

Eligible subjects were double-match
randomized by a blinded third party until
the 16th subject was reached; at that point a
stratification procedure according to
gender, age and ethnicity occurred.

Moderate sample size (N=47)
Provider sample size (N=1)
25% attrition rate, and lack of
objective sleep and pain measures.
Although these limitations.

Objective Measures: Sleep and Pain
Diaries, Insomnia Severity Index (ISI), Pain
Disability Index (PDI), Multidimensional
Pain Inventory (MPI) and the Beck
Depression Inventory (BDI). The Epworth
Sleepiness Scale (ESS), the
Multidimensional Fatigue Index (MFI)

CBT self-help with clinical support in PC settingeffective by any PCP (nurse, social worker, or GP)
Brief CBT did not outperform treatment as usual.
CASP= High

Meta-analytic component employed.
Test for initial differences, management of
missing data and multiple comparison and
false discovery addressed.

Analyses found no significant differences in patient
outcomes between groups receiving CBT from trained
clinicians and those receiving routine care.

US-based; different health system and
potentially different NP
practice/education and views on CBT

Seventy-eight percent of the subjects who received
CBT-I were designated as treatment responders (vs.
22% of the controls) and 42% were designated as in
remission (vs. 11% of the controls).
Confirmatory analysis using the Epworth Sleepiness
Scale revealed that improved sleep was predictive of
decreased daytime symptoms such as excessive
daytime sleepiness.
The groups did not significantly differ on the mood
measures or sleep diary measures of pain.
CASP= High

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Article/Study Design & Overview

Strengths
Sound statistical Analysis

Limitations

Utility/Important Findings

Knoerl, R (2015)

Strength in being an integrative literature
review

Location of CBT session delivery not
described

CBT reduced pain intensity in 43% of trials.

Samples provided variation in adult age,
gender, and condition being treated.

Selected PCP from variety of settings
including NPs, GPs, counsellors,
psychiatrists, psychologists, and
social workers.

Integrative literature review to
evaluate to determine (a) which
CBT doses, delivery methods,
strategies, and follow-up periods
have been explored in recent
intervention studies of
individuals with chronic pain and
(b) whether the outcomes
described in the selected studies
were consistent with
recommendations.
Intervention: CBT
Lewis, H. (2013)
A cross-sectional study to
explore and understand primarycare therapists' perceived
competence in providing CBT to
people with medically
unexplained symptoms
Intervention: Comprehensive
CBT interventions.
Mathieson, F., et al. (2013)
Case review study to develop a
brief intervention that would
meet the needs of patients with
sub-threshold anxiety or
depression and be offered by
clinicians working in primary
care.
Intervention: Two-fold
1) two focus interviews were
conducted to establish a
collaborative CBT manual for
PCPs in PC settings then

Selected PCP from variety of settings
including NPs, GPs, counsellors,
psychiatrists, psychologists, and social
workers.

The efficacy of online and in-person formats were
comparable
CASP= Moderate

May not be generalizable to NP
practice or primary care practice

Sample size (N=35).

Provides a good description of the role for
mental specialists to deliver CBT but
recognized knowledge was limited.

Small sample (N-8)
Not generalizable to CNCP
conditions that are well understood
US-based; different health system and
potentially different NP
practice/education and views on CBT

Mental Health CBT Therapists knew little about MUS
or CBT application for pain conditions.
Engaging patients with CP and MUS crucial- requiring
more than 15 min visits.
No protocol/literature for CBT application in MUS/CP
could be found easily.
CASP= Moderate

Thorough critical review of literature before
preforming intervention.

Small provider sample (N=5)

CBT interventions needed to be brief to be practical
and financially viable in PC.

Small participant sample (N-14)
Evaluation of intervention competency
through multiple modes.
Outcomes Measures: Nil- discussed effects
of PCP delivered CBT in interviews with
researchers post intervention

Patients rated the sessions as very helpful and practical.
Not generalizable
Confusing study to read

There were significant reductions in distress levels for
patient (n=14)- no control group to compare.

No control group

CASP= Moderate

Limited statistical analysis
New Zealand- based; different health
system and potentially different NP
practice/education and views on CBT

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Article/Study Design & Overview

Strengths

Limitations

Utility/Important Findings

evaluated the use of that manual
in practice with participants
Mignogna, J. et al. (2018).

Provider Sample (N=18)

No control group

Patient Sample (N= 180).

Limited to one primary care setting

The therapeutic relationship, individual patient factors,
and system-level factors were critical drivers guiding
how providers adapted EBP delivery to improve the
“fit” into their clinical practice.

Randomized into groups based on number
of CBT sessions attended (4, 5, or 6 or
more sessions).

Summative rather than formative
evaluation

Pre-post study design to explored
providers’ perspectives on
fidelity to a manualized brief
cognitive behavioral therapy
(CBT) as delivered in primary
care clinics.

Sound statistical Analysis
Interventions: used the Reach,
Effectiveness, Adoption,
Implementation, and
Maintenance (RE-AIM)
framework to evaluate key
effectiveness and implementation
outcomes
Richmond, M. (2015)

Objective Measures: Interviews with
providers.

Intervention: Cognitive
Beahvioral approaches

CASP= High

United States based; different health
system and potentially different NP
practice/education and views on CBT
RCT Studies (N=23)

Systematic review with metaanalysis to assess whether
cognitive behavioral (CB)
approaches improve disability,
pain, quality of life and/or work
disability for patients with low
back pain (LBP) of any duration
and of any age.

Collecting one-time interviews at the
end of the study most likely limited
the scope of providers’ responses,
given the length of time

Adaptations were generally viewed as acceptable by
study fidelity experts and helped to more clearly define
delivery procedures to improve future implementation
efforts.

Location of CBT session delivery not
described

Natural groups design- longitudinal
Samples provided variation in adult age,
gender, and condition being treated.

Selected PCP from variety of settings
including NPs, GPs, counsellors,
psychiatrists, psychologists, and
social workers.

Recruited from unknown setting
Selected PCP from variety of settings
including NPs, GPs, counsellors,
psychiatrists, psychologists, and social
workers.
Sound statistical analysis

May not be generalizable to NP
practice or primary care practice

CB interventions yield long-term improvements in
pain, disability and quality of life in comparison to no
treatment and other guideline-based active treatments
for patients with LBP of any duration and of any age.
Trials varied considerably in methodological quality,
and in intervention factors such as provider, mode of
delivery, dose, duration, and pragmatism, there were
several examples of lower intensity, low cost
interventions that were effective.
CASP= Moderate

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Appendix D
Levels of Evidence
Level 1 - Systematic review & meta-analysis of randomized controlled trials;
clinical guidelines based on systematic reviews or meta-analyses
Level 2 - One or more randomized controlled trials
Level 3 - Controlled trial (no randomization)
Level 4 - Case-control or cohort study
Level 5 - Systematic review of descriptive & qualitative studies
Level 6 - Single descriptive or qualitative study
Level 7 - Expert opinion