Training and Clinical Preparation of Nurses Delivering Cognitive Behavioral Therapy: A Systematic Review

ABSTRACT

Background

Cognitive behavioral therapy (CBT) is increasingly being incorporated into nursing practice across mental health and chronic care settings. However, limited attention has been given to how nurses delivering CBT interventions are trained, supervised, and professionally prepared within existing research.

Aim

This systematic review aimed to examine the characteristics, training, supervision, and reported outcomes of CBT interventions delivered by nurses with formal or structured CBT preparation across clinical settings.

Methods

Following PRISMA guidelines, a systematic search was conducted across five major databases. Eligible studies included interventional studies that examined CBT interventions delivered by nurses with formal, structured, or supervised CBT training. Data extraction and methodological quality assessment were conducted independently by two reviewers using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

Results

Five studies met the inclusion criteria, involving diverse clinical populations including individuals with schizophrenia, adults with chronic illnesses, and pediatric family caregivers. Considerable heterogeneity was observed in nurses' educational preparation, intervention characteristics, supervision structures, and outcome measures. Training pathways ranged from brief certification programs to extended supervised clinical training. Across studies, nurse‐delivered CBT interventions were associated with improvements in psychological and functional outcomes. However, the overall methodological quality of the evidence was weak. Common methodological limitations included small sample sizes, lack of blinding, attrition, and inconsistent reporting of competency assessment and intervention fidelity.

Linking Evidence to Action

Healthcare organizations considering nurse‐delivered CBT interventions should establish clearly defined training pathways, structured supervision, competency assessment, and explicit procedures for monitoring intervention fidelity. Given the limited and methodologically weak evidence base, implementation should be cautious, supported by standardized intervention protocols, and accompanied by systematic evaluation of clinical and implementation outcomes.

Trail Registration

CRD420251148159

1. Introduction

As healthcare systems increasingly emphasize integrated and person‐centered care, nurses are becoming more involved in addressing patients' psychological and behavioral needs alongside physical health concerns (American Nurses Association (ANA) ²⁰²¹; Robbins ²⁰²¹). This shift has contributed to the growing incorporation of psychological and behavioral interventions across psychiatric, primary care, and chronic disease settings. Among these approaches, cognitive behavioral therapy (CBT) has emerged as an evidence‐based intervention that may support emotional, behavioral, and self‐management outcomes in clinical practice (J. S. Beck ²⁰¹¹).

CBT is a psychotherapeutic approach that focuses on modifying maladaptive patterns of thinking and behavior to improve emotional and functional outcomes (J. S. Beck ²⁰¹¹). Core CBT components include cognitive restructuring, behavioral activation, psychoeducation, and problem‐solving strategies. Because CBT involves structured therapeutic techniques and clinical decision‐making, its delivery typically requires formal training, supervised practice, and competency development. In nursing‐related settings, CBT principles have increasingly been incorporated into mental health and chronic disease interventions (Currid et al. 2011; Yoshinaga et al., 2024). However, substantial variability remains in the extent and nature of nurses' CBT preparation across clinical and educational contexts, particularly between brief study‐specific instruction and more formal CBT training and supervision.

Formal CBT training programs are offered internationally by accredited institutions and professional organizations, including the Beck Institute for Cognitive Behavior Therapy in the United States (Beck Institute ²⁰²⁴), the British Association for Behavioral and Cognitive Psychotherapies in the United Kingdom (BABCP ²⁰²³), and similar frameworks in Sweden (SABT ²⁰²²) and Canada (CFMHN ²⁰²³). These programs commonly include theoretical instruction, supervised clinical practice, case formulation, and competency‐based training. However, the structure, duration, supervision requirements, and professional recognition associated with CBT training vary considerably across clinical and educational contexts. As a result, distinctions may exist between CBT‐informed interventions delivered following brief study‐specific instruction and those delivered by nurses with more formal CBT preparation and supervision.

Nurses play essential roles in addressing patients' physical and psychological needs across diverse healthcare settings. A recent concept analysis (Anipah et al. 2025) highlighted nurses' contributions to CBT‐based interventions through therapeutic support, patient guidance, and ongoing follow‐up. These expanding roles underscore the importance of appropriate training and professional competence, including the knowledge, clinical judgment, and skills required for safe and effective care (Mrayyan et al. 2023). At the same time, limited formal education, supportive policy frameworks, and structured clinical tools remain important barriers to the broader implementation of nurse‐delivered CBT interventions in nursing practice.

Previous studies have reported positive outcomes from nurse‐delivered CBT‐informed interventions in psychiatric and chronic care settings, including reductions in anxiety, depression, and disease‐related distress, as well as improvements in coping and self‐management (Van Lieshout et al. 2022; Wong et al. ²⁰²⁵; Murray et al. ²⁰²³). However, many of these interventions relied on brief study‐specific instruction rather than formal CBT education and provided limited information regarding therapeutic competency, supervision, and intervention fidelity. In addition, some interventions incorporated selected CBT‐related techniques, such as mindfulness‐based approaches or psychoeducation, without implementing comprehensive CBT protocols or structured case formulation (Fort‐Rocamora et al. ²⁰²⁴). Consequently, considerable variability exists in how nurse‐delivered CBT interventions are defined and implemented across the literature.

Although CBT‐informed approaches are increasingly integrated into nursing care, less attention has been paid to interventions delivered by nurses with formal CBT preparation and structured supervision. Existing evidence often groups nurses within multidisciplinary teams or provides limited descriptions of nurses' therapeutic training, supervision, and clinical roles, making it difficult to compare interventions across settings. Moreover, inconsistent reporting of competency development, supervision, and intervention fidelity limits understanding of how nurse‐delivered CBT interventions are prepared and implemented in practice. Accordingly, this systematic review (SR) aimed to examine the characteristics, training, and reported outcomes of CBT interventions delivered by nurses with formal CBT preparation across clinical settings. Specifically, the SR examined targeted populations, intervention characteristics, training and supervision structures, and reported clinical and psychosocial outcomes.

2. Methods

The current SR review is guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA 2020) framework (Page et al. 2020). The review protocol was prospectively registered in the PROSPERO international database for systematic reviews [Registration ID: CRD420251148159], thereby ensuring methodological transparency and adherence to established evidence synthesis standards.

2.1. Searching Strategy

A comprehensive search was carried out across five major databases: PubMed, EMBASE, Scopus, Web of Science, and ProQuest Nursing & Allied Health. The search was conducted between June and July 2025, in close collaboration with a senior medical librarian specializing in systematic review methodology. The librarian validated and refined the search terms to ensure alignment with controlled vocabulary systems (MeSH and Emtree) and the indexing structures of the relevant databases.

No restrictions were placed on the publication year. This methodological choice aimed to ensure that all empirical literature examining CBT interventions delivered by nurses was included. Since CBT has developed over several decades and the roles and training of nurses have differed across historical periods and healthcare systems, setting a date limit could have unintentionally excluded important early or contextual studies. Therefore, allowing an unrestricted time frame increased the search's sensitivity and supported a more comprehensive and historically informed review of the literature.

The search strategy focused on three main conceptual areas. The first relates to Cognitive Behavioral Therapy, including variations such as “cognitive behavioral therapy,” “cognitive psychotherapy,” and “behavior therapy.” The second covers Nursing Providers, using broad, truncated terms (e.g., nurse) that encompass all nursing roles, including psychiatric and advanced practice nurses. The last area centres on Clinical and Psychosocial Outcomes, including treatment adherence/compliance, symptom severity, and mental health indicators. The initial search returned approximately 930 records across all databases (see Figure 1).

FIGURE 1.

PRISMA flow diagram of the study selection process.

2.2. Study Selection

All records collected from the database search were first imported into Zotero Reference Manager software (Forbes et al. 2024), where 333 duplicate records were automatically identified and removed. Next, the remaining 597 records were transferred to Rayyan, a web‐based platform for systematic review management (Pellegrini and Marsili 2021). An additional 14 duplicates were manually removed in Rayyan, bringing the total to 583 sources for screening.

The screening process followed a two‐stage approach, starting with initial title and abstract screening, then proceeding to a full‐text review. During both stages, two reviewers, blinded to one another, independently evaluated all studies according to the predefined inclusion and exclusion criteria. The reviewers worked separately and remained blinded to each other's decisions until each stage was complete. After independent screening, the results were compared, and any discrepancies were discussed. In cases of disagreement, a joint consensus decision was made to determine whether each study should advance to the next stage or be excluded. After the title and abstract screening, 112 records were kept for full‐text review. During the full‐text evaluation, all 112 studies were examined in detail, and five studies met all the inclusion criteria and were included in the final synthesis (see Figure 1).

2.3. Eligibility Criteria

Studies were eligible for inclusion if they met all of the following criteria. Only interventional studies (such as randomized controlled trials, quasi‐experimental studies, or controlled pre–post designs) that reported clinical, psychological, behavioral, or functional outcomes associated with nurse‐delivered CBT interventions were included. Eligible studies were those in which the intervention was delivered by nurses described as having formal, structured, or supervised CBT‐related training beyond brief study‐specific instruction. Studies that involved only brief orientation sessions focused on isolated techniques without broader CBT training or supervision were excluded. Studies had to report clinical, psychological, or behavioral outcomes, such as symptom reduction, improved treatment adherence, enhanced coping, or enhanced mental well‐being. Additionally, only articles published in English and available in full text were included to allow a thorough assessment of methodological quality and intervention details.

2.4. Data Extraction

Data extraction was conducted systematically using a structured form created for this SR. Information was collected from each eligible study regarding: author, year, and country; study design and objectives; intervention framework and delivery setting; characteristics and qualifications of the nurses providing CBT; sample size and population; data collection and assessment tools; and reported clinical and psychosocial outcomes. Additional data were extracted regarding the nature of nurses' CBT preparation, supervision arrangements, and descriptions of therapeutic competency or intervention fidelity when reported. Intervention‐related information was also extracted, including the type of intervention (individual or group), duration, and core CBT components.

Data were independently extracted by two reviewers to ensure accuracy and minimize bias. Discrepancies in the extracted information were discussed until consensus was reached. The extracted data were then organized into two summary tables. Table 1 presents the general characteristics of the included studies (design, participants, instruments, and outcomes), and Table 2 summarizes the characteristics of the CBT interventions, including training and supervision features when available, as well as the main findings.

TABLE 1.

Study characteristics.

Authors/YOP/Country	Study design EPHPP a	Aim	Treatment settings	Healthcare team delivered the intervention	Sample and population and data collection	Instruments	Conclusion
Çapar Çiftçi and Kavak Budak 2022 Turkia	Quasi‐experimental design with pretest–posttest control group EPHPP = 3 a	To determine the effect of CBT‐based psychoeducation on internalized stigma and functional remission in individuals diagnosed with schizophrenia	Community Mental Health Center	CBT nurses with 52 h of formal CBT training and certification Firat University Continuing Education Center approved CBT certification	N = 100 participants (50 in each group)	Internalized Stigma of Mental Illness Scale (ISMI) Functional Remission in General Schizophrenia Scale (FROGS)	Overall, the CBT‐based psychoeducation program was effective in improving both psychological and functional outcomes among individuals with schizophrenia
Doherty et al. 2021 UK	Pre–post uncontrolled intervention study EPHPP = 3 a	To test the feasibility of an online diabetes‐focused CBT‐based intervention in Type 1 diabetes delivered by diabetes specialist nurses (DSNs)	Four secondary‐care hospitals	Diabetes Specialists Nurses specialize in CBT CBT specialization consists of a short training program and 6 months of supervision and acknowledgment with a structured CBT manual tailored for diabetes self‐management	N = 71 3 time‐point assessment: baseline, 6, and 12 months following recruitment	Clinical measure: HbA1c at baseline, 6 months, and 12 months Psychological measures: PHQ‐9 (depression) GAD‐7 (anxiety) Diabetes Distress Scale (DDS)	The authors concluded that real‐time, online, text‐based CBT delivered by trained Diabetes Specialist Nurses is feasible, acceptable, and potentially beneficial for adults with Type 1 diabetes and poor glycaemic control
Han et al. 2020 China	RCT pilot EPHPP = 3 a	To develop and evaluate a culturally tailored cognitive behavioral therapy (CBT) program for people living with HIV (PLWH) in China	Clinical hospital setting	Community nurse with Level II certification as a national psychological counselor	N = 20, 10 – intervention and 10 in the control group The intervention outcomes were measured at the baseline (T0), after 10 weeks of intervention (T1), and at a 6‐month follow‐up (T2)	Mental Health Outcomes HADS (Hospital Anxiety and Depression Scale) PHQ‐4 for screening during recruitment ART Medication Adherence Self‐reported adherence (two‐item scale) Visual Analog Scale (VAS) Medication Possession Ratio (MPR) from pharmacy refill data	10‐week group‐based CBT program is both feasible and acceptable It demonstrated promising short‐term effects on reducing anxiety and improving ART adherence, although effects were not maintained at 6 months
Turkington et al. 2008 UK	RCT EPHPP = 3 a	The study aimed to evaluate the medium‐term durability (5‐year follow‐up) of cognitive‐behavioral therapy (CBT) for individuals with schizophrenia who continued to experience persistent hallucinations and delusions despite adequate antipsychotic treatment	Multiple outpatient psychiatric clinics	Psychiatric CBT nurses They used a published CBT manual (Kingdon and Turkington, 2005)	N = 90 Baseline: n = 46, intervention (CBT) group n = 44, control 5‐year follow‐up assessment (N = 56): n = 31, intervention (CBT)group n = 28, control	CPRS—Comprehensive Psychopathological Rating Scale SANS—Scale for the Assessment of Negative Symptoms SCS—Schizophrenia Change Scale MADRS—Montgomery–Åsberg Depression Rating Scal	The study concludes that CBT provides significant and durable medium‐term benefits, particularly for overall and negative symptoms in people with medication‐refractory schizophrenia
Wu et al. 2024 China	RCT EHPPH = 3	To determine whether a structured nurse‐led CBT program for parents could improve: parents' mental health (anxiety, depression, sleep), parental attitudes toward epilepsy, satisfaction with nursing care indirectly improve seizure severity and treatment compliance in their children	University hospital in China	Four neurology‐specialized nurses, under supervision of a senior clinical psychologist Nurse Training Included: 12 months of preparation 40 h theory 100 h practical training Skills in: assessing psychological state, one‐to‐one therapeutic communication, CBT cognitive restructuring techniques, behavioral strategies (e.g., adherence training, relaxation), administering and interpreting assessment tools	N = 238 parent–child dyads: Intervention group: 117 Control group: 121	Children: Seizure severity (customized 4‐level scale) Treatment compliance Parents: STAI: State–Trait Anxiety Inventory CES‐D: Center for Epidemiologic Studies Depression Scale PSQI: Pittsburgh Sleep Quality Index CPATE: Chinese Public Attitudes Toward Epilepsy Scale Satisfaction with nursing care (0–100 scale)	The study concludes that a nurse‐led CBT program for parents of CWE effectively improves parental psychological well‐being and satisfaction with nursing care, and may indirectly reduce seizure severity in children. This approach is presented as a promising long‐term disease‐management strategy for pediatric epilepsy

^a EPHPP‐Effective Public Health Practice, Quality assessment tool for quantitative studies: (degree of Q/A: 1‐strong, 2‐moderate, 3‐weak).

TABLE 2.

Characteristics of the intervention.

Authors/YOP	Type of intervention	Content of the intervention	Health outcomes
Çapar Çiftçi and Kavak Budak 2022 Turkia	Group intervention 8 sessions: 60–90 min per week	The intervention was a CBT‐based psychoeducation program, incorporating: Cognitive–behavioral strategies to reduce internalized stigma Group exercises focused on identifying and modifying negative thoughts Activities aimed at improving functional remission Development of adaptive behaviors and coping skills Enhancement of emotional awareness, social functioning, and daily functioning Psychoeducational discussions and in‐group practice tasks	Post‐test results: The FROGS mean score of the experimental group was significantly higher than that of the control group (p < 0.05) The ISMI mean score of the experimental group was significantly lower compared to the control group (p < 0.05) This indicates that the intervention significantly improved recovery (higher FROGS) and significantly reduced internalized stigma (lower ISMI)
Doherty et al. 2021	Diabetes Online Therapy (DOT) Individual therapy with structured CBT sessions, 50 min each	CBT elements Identifying and restructuring unhelpful thoughts Behavioral activation Problem‐solving skills Goal setting Coping strategies for emotional distress Diabetes‐specific CBT content Addressing diabetes‐related cognitive distortions Reducing diabetes distress Improving self‐management behaviors Enhancing confidence in glucose monitoring and insulin management	Clinical outcomes Significant reduction in HbA1c at 12 months (−6.2 mmol/mol, p = 0.038). Improvement indicates better glycaemic control Psychological outcomes Reduction in depression symptoms Reduction in anxiety symptoms Reduction in diabetes‐related emotional distress Improvements were more pronounced among participants with higher baseline distress
Han et al. 2020 China	Group intervention, based on the Cognitive Behavioral Stress Management (CBSM) model 10 weekly sessions, 2 h each	Cognitive restructuring Relaxation training (mindfulness, deep breathing) Discussion of culturally relevant topics (stigma, intimacy, relationships, ART challenges) Psychoeducation Expressive‐supportive activities	Feasibility Attendance rate: 60% No dropouts in the intervention group Most common absence reasons: busy schedule, distance, weather Acceptability All participants reported benefiting from the intervention 100% expressed willingness to participate in future sessions No adverse events reported Preliminary Outcomes Significant improvement in anxiety at T1 (p = 0.041) Significant improvement in self‐reported ART adherence (p = 0.033) No significant differences in depression, MPR, or long‐term outcomes at T2 Effects diminished by 6‐month follow‐up
Turkington et al. 2008 UK	CBT (Individual Therapy) 20 sessions over nine months	Engagement and normalization Developing stress–vulnerability formulations Coping strategies for auditory hallucinations Cognitive restructuring for delusions Activity scheduling and pleasure–mastery techniques Emotional labeling Addressing negative beliefs and medication attitudes Relapse prevention planning	Overall Symptom Severity CBT demonstrated a more durable improvement in overall symptoms compared to BF at the 5‐year follow‐up Negative Symptoms CBT showed a moderate to strong sustained effect on negative symptoms (SANS), with significantly lower scores than BF Positive Symptoms and Depression No significant differences between groups at 5 years for: SCS (positive symptoms) MADRS (depression) Both groups‐maintained improvements relative to baseline Hospitalizations No significant differences in: Number of readmissions Number of days hospitalized (though CBT showed a non‐significant trend toward fewer total hospital days)
Wu et al. 2024 China	individual (one‐to‐one) CBT sessions 1 month (two sessions per week, 30–40 min)	Cognitive Component (Weeks 1–2): Correcting misconceptions about epilepsy Psychoeducation with videos/pictures Discussion of attitudes toward long‐term medication Identification and reframing of negative emotions Guidance to access psychological support when needed Behavioral Component (Week 3): Medication behavior training (pill organization, recording doses) Training parents to anticipate adverse events Relaxation training with guided imagery and music (20 min daily) Reinforcement (Week 4): Reviewing medication logs Reward system for children adhering to medication Additional tailored behavioral and cognitive interventions	For Children Seizure severity significantly improved in the intervention group (94.86% vs. 88.43%, p = 0.048) No significant difference in treatment compliance between groups For Parents Parents receiving the CBT intervention reported: Lower anxiety (state and trait) Lower depression scores Better sleep quality More positive attitudes toward epilepsy Higher satisfaction with nursing care (p < 0.001) Correlation analysis showed that better parental mental health was associated with reduced seizure severity in children, suggesting an indirect beneficial effect

2.5. Quality Assessment

The methodological quality and risk of bias of all included studies were assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool (Thomas et al. 2004). The EPHPP was selected because it enables standardized evaluation of both randomized and non‐randomized intervention studies, consistent with the methodological diversity of the included studies. The tool has been widely used in nursing and public health research and demonstrates strong methodological validity and inter‐rater reliability (Armijo‐Olivo et al. ²⁰¹²; de Sousa et al. ²⁰²²; Lousen et al. ²⁰²⁵).

The EPHPP evaluates domains including selection bias, study design, confounders, blinding, data collection methods, intervention integrity, and analysis. Each domain is rated as strong, moderate, or weak, resulting in an overall global quality rating (Thomas et al. 2004). Two reviewers independently assessed all included studies, and disagreements were resolved through consensus. Final quality ratings are presented in Table 1.

2.6. Data Synthesis

Given the methodological and contextual diversity among the included studies, a narrative synthesis approach was used in line with the Synthesis Without Meta‐Analysis (SWiM) reporting guidelines (Campbell et al. 2020). Extracted data were organized to facilitate comparison of study characteristics, intervention components, and primary outcomes. Particular attention was given to variability in the structure of CBT training, supervision arrangements, intervention implementation, and descriptions of therapeutic competency across studies.

3. Results

3.1. Study Characteristics

Five studies published between 2007 and 2024 met the inclusion criteria and were included in this review. The studies examined CBT interventions delivered by nurses with formal or structured CBT‐related training across diverse clinical populations and healthcare settings. In terms of geographical distribution, the studies were conducted in China (n = 2) (Han et al. 2020; Wu et al. ²⁰²⁴), the United Kingdom (n = 2) (Doherty et al. 2021; Turkington et al. ²⁰⁰⁸), and Turkey (n = 1) (Çapar Çiftçi and Kavak Budak ²⁰²²). All included studies were interventional, with three employing a randomized controlled trial (RCT) design (Han et al. 2020; Turkington et al. ²⁰⁰⁸; Wu et al. ²⁰²⁴). One study used a quasi‐experimental design (Çapar Çiftçi and Kavak Budak ²⁰²²), and another used a single‐group pre–post design (Doherty et al. 2021).

3.2. Quality Assessment

All five studies included in this review were rated as weak (Level 3) evidence, reflecting methodological limitations that may undermine the strength and generalizability of their findings. The specific reasons for these ratings included the absence of a control group (Doherty et al. 2021), a high attrition rate during follow‐up (Turkington et al. 2008), group imbalance between intervention and control participants (Wu et al. 2024), a small sample size (Han et al. 2020), and a quasi‐experimental design with partial control for confounders and no blinding (Çapar Çiftçi and Kavak Budak ²⁰²²).

Despite these limitations, all studies provided clear descriptions of intervention protocols and used validated measurement tools, thereby contributing to internal consistency within their respective designs. However, the overall body of evidence should be interpreted with caution due to the generally weak methodological rigor observed across studies.

3.3. Population and Clinical Settings

The included studies were conducted across diverse psychiatric and chronic care populations, reflecting the broad clinical application of nurse‐delivered CBT interventions. Two studies focused on psychiatric populations diagnosed with schizophrenia (Çapar Çiftçi and Kavak Budak ²⁰²²; Turkington et al. ²⁰⁰⁸), while three studies involved populations affected by chronic medical conditions, including individuals living with HIV (Han et al. 2020), adults with Type 1 diabetes (Doherty et al. 2021), and parents of children with epilepsy (Wu et al. 2024).

The interventions were implemented across a range of healthcare settings, including community mental health centers, psychiatric outpatient clinics, secondary‐care hospitals, and university‐affiliated medical centers. Across studies, CBT interventions targeted a variety of psychological and behavioral outcomes, including internalized stigma, depressive symptoms, anxiety, treatment adherence, emotional adjustment, coping, self‐management, sleep quality, and relapse prevention. Considerable heterogeneity was observed in both the targeted populations and the clinical implementation of CBT interventions across settings. In particular, some interventions focused directly on psychiatric symptom management, whereas others emphasized coping with chronic illness, caregiver distress, or behavioral self‐management in long‐term medical conditions.

3.4. CBT Training and Qualifications of Nurses

All five included studies showed substantial variability in the structure, duration, and reporting of nurses' CBT‐related training and supervision. The level of detail about nurses' qualifications also varied considerably across studies. In Çapar Çiftçi and Kavak Budak (2022), nurses completed a formal 52‐h CBT training program accredited by Fırat University's Continuing Education Center, with both theoretical and practical components. Doherty et al. (2021) described a six‐month CBT‐focused educational program for diabetes nurses that addressed behavioral self‐regulation and diabetes‐related distress; however, the total number of training hours and supervision procedures were not specified.

Considerable variability was also observed across studies conducted in China. Han et al. (2020) reported that community nurses held a national‐level counseling certificate in psychological counseling skills, though the extent of formal CBT‐specific training was not clearly described. In contrast, Wu et al. (2024) described a more extensive 12‐month CBT certification program that included 40 h of theoretical coursework and 100 h of supervised clinical practice focused on psychological assessment, therapeutic communication, and CBT intervention delivery. Similarly, Turkington et al. (2008) provided limited detail on nurses' formal CBT preparation. However, the intervention followed a manualized CBT protocol and included ongoing supervision by experienced CBT therapists. Across studies, descriptions of competency assessment, therapeutic fidelity, and supervision procedures were inconsistent or incomplete.

3.5. Type, Duration, and Content of CBT Interventions

The included studies implemented both group‐based and individual CBT interventions, with substantial variability in intervention duration, intensity, and therapeutic focus across settings. Two studies (Çapar Çiftçi and Kavak Budak ²⁰²²; Han et al. ²⁰²⁰) used group‐based CBT interventions targeting psychosocial functioning, coping, emotional regulation, and treatment adherence among individuals with schizophrenia or HIV. These interventions incorporated components such as psychoeducation, cognitive restructuring, behavioral activation, communication skills, and problem‐solving strategies delivered over 8–10 weekly sessions.

Three studies (Doherty et al. 2021; Turkington et al. ²⁰⁰⁸; Wu et al. ²⁰²⁴) implemented individual CBT interventions that differed considerably in duration and clinical focus. Intervention length ranged from a one‐month program for caregivers of children with epilepsy (Wu et al. 2024) to a six‐month intervention for adults with Type 1 diabetes (Doherty et al. 2021) and a 20‐session protocol delivered over eight months for individuals with schizophrenia (Turkington et al. 2008). Across studies, commonly reported CBT components included psychoeducation, cognitive restructuring, behavioral activation, emotional regulation, relaxation techniques, coping skills, and problem‐solving strategies. However, intervention structure, intensity, supervision, and standardization varied considerably across studies.

3.6. Reported Outcomes of Nurse‐Delivered CBT Interventions

Across the included studies (n = 5), nurse‐delivered CBT interventions were associated with improvements across psychiatric and chronic care populations, although the reported outcomes varied by population, intervention focus, and study design. Among individuals with schizophrenia, Çapar Çiftçi and Kavak Budak (2022) reported improvements in internalized stigma and functional remission following an eight‐session psychoeducational CBT program, whereas Turkington et al. (2008) reported improvements in psychotic symptoms and reductions in relapse and hospitalization rates over longer follow‐up periods.

In chronic illness populations, Han et al. (2020) reported short‐term improvements in anxiety, depression, self‐efficacy, and treatment adherence among people living with HIV, although these effects appeared to diminish over time. Doherty et al. (2021) reported reductions in diabetes‐related distress and depressive symptoms among adults with Type 1 diabetes participating in an online nurse‐delivered CBT intervention, with improvements in glycemic control observed among participants with higher baseline distress. Wu et al. (2024) reported improvements in anxiety, depression, sleep quality, coping, and communication among parents of children with epilepsy following a brief CBT intervention.

Overall, the included studies suggest that nurse‐delivered CBT interventions may contribute to psychological, behavioral, and functional improvements across diverse populations. However, interpretation of the findings remains limited by methodological weaknesses, including small sample sizes, high attrition rates, reliance on self‐reported measures, lack of control groups, limited follow‐up, heterogeneous intervention structures, and inconsistent reporting of training, supervision, and therapeutic fidelity.

4. Discussion

This SR identified limited and methodologically heterogeneous evidence on CBT interventions delivered by nurses with formal or structured CBT training. Only five studies met the inclusion criteria, and all demonstrated methodological limitations that restrict the strength and generalizability of the findings. Nevertheless, substantial variability was observed in how nurse‐delivered CBT interventions were trained, supervised, implemented, and reported across clinical settings.

The included studies showed considerable variation in the structure and reporting of nurses' CBT preparation, ranging from brief structured training programs to extended supervised certification pathways. Variability was also evident in supervision procedures, competency development, and therapeutic fidelity. These findings align with broader evidence suggesting that therapists' prior training and clinical experience influence the development of competence during CBT training (Henrich et al. 2023). In addition, instructor‐led and supervised training models may be particularly important for maintaining the quality and consistency of nurse‐delivered CBT interventions (Henrich et al. 2023). Taken together, the findings suggest that implementation may depend not only on the intervention itself but also on the educational, supervisory, and organizational contexts in which CBT is delivered. The included studies were conducted across diverse national and healthcare settings characterized by different educational, regulatory, and professional frameworks, which may partly explain the variability observed across studies.

One approach to addressing the variability identified in this review is to train nurses to deliver evidence‐based, manualized CBT‐based interventions. Manualized programs provide structured session content, standardized intervention materials, and clearly defined delivery procedures that, when combined with appropriate provider training, competency assessment, and supervision, may support intervention fidelity. The evidence‐based Creating Opportunities for Personal Empowerment (COPE) program provides an example of such an approach. COPE 7‐session brief interventions have been delivered by nurses, including advanced practice nurses and pediatric as well as family nurse practitioners, in outpatient, primary care practices with reimbursement, K‐12 schools, universities, and other clinical settings for more than a decade (Lusk and Melnyk 2011; Kozlowski et al. ²⁰¹⁵; Melnyk ²⁰²⁴). These studies have demonstrated the feasibility of nurse‐led delivery and have reported improvements in outcomes, such as anxiety, depressive symptoms, stress, coping knowledge, self‐esteem, and functioning, while more recent COPE‐based interventions have also demonstrated positive mental health and healthy lifestyle behavior outcomes in advanced practice nurse‐delivered care with pregnant depressed, anxious, and stressed women (Gennaro et al. 2024). Although the available findings cannot be generalized to all nursing roles, populations, or healthcare settings, COPE illustrates how manualized CBT‐based intervention content and structured provider preparation may promote greater consistency and fidelity in nurse‐delivered CBT‐based care.

The included studies were conducted across diverse national and healthcare contexts, including the UK, China, and Turkey, where educational, regulatory, and professional frameworks surrounding nurse‐delivered CBT differ substantially. In the UK, CBT training for nurses has historically developed through structured, supervised professional pathways integrated into healthcare systems (Gournay, 2000). The UK studies included in this review reflected nurses delivering CBT interventions across both psychiatric and chronic care settings (Doherty et al. 2021; Turkington et al. ²⁰⁰⁸). In China, nurse‐delivered CBT interventions appeared to be implemented within diverse workforce and organizational contexts, including settings where access to specialized mental health professionals may be limited (Yue et al. 2022). The included studies demonstrated variability in nurses' CBT preparation, supervision, and clinical roles (Han et al. 2020; Wu et al. ²⁰²⁴). Similarly, the Turkish study reflected differences in professional and educational structures surrounding nurse‐delivered CBT interventions, including variability in psychotherapy training opportunities and supervision frameworks (Türkçapar et al. 2022; Çapar Çiftçi and Kavak Budak ²⁰²²). Taken together, these international differences suggest that nurse‐delivered CBT interventions are implemented across diverse educational and organizational environments, which may partly explain the variability observed in training structures, supervision practices, and intervention delivery.

CBT interventions are delivered by a range of healthcare professionals and are not exclusive to nursing practice. Previous literature has described CBT practitioners from diverse professional backgrounds across healthcare settings (Butcher and Chigwedere 2022). This multidisciplinary context highlights the importance of clearly defined training pathways, supervision arrangements, and competency frameworks across disciplines.

The findings of the current review demonstrated substantial variability in how nurses' CBT preparation, supervision, and intervention fidelity were reported. Given nurses' increasing involvement in CBT‐informed interventions across psychiatric and chronic care settings, clearer reporting and more consistent educational and supervisory frameworks may support safer and more transparent implementation of nurse‐delivered CBT interventions in clinical practice (Butcher and Chigwedere 2022).

4.1. Policy Implications

The SR findings highlight the importance of accessible and clearly structured CBT training opportunities for nurses involved in psychological and behavioral interventions across healthcare settings. The substantial variability observed in training, supervision, and competency reporting across studies suggests a need for greater consistency and transparency in the preparation and implementation of nurse‐delivered CBT interventions. Clearer educational and supervisory frameworks, including explicit descriptions of training pathways, competency expectations, and procedures for intervention fidelity, may support safer, more consistent implementation across clinical settings.

Foundational exposure to CBT concepts could also be introduced during pre‐licensure RN education. Such exposure may familiarize nursing students with basic CBT principles, their potential relevance to nursing practice, and available opportunities for advanced post‐licensure training. Early exposure may also help interested students identify future professional development pathways. However, introductory education during pre‐licensure programs should not be considered sufficient preparation for the independent delivery of CBT, which would continue to require structured training, competency assessment, and appropriate supervision.

4.2. Linking Evidence to Action

Define minimum CBT training requirements for nurses according to the complexity of the intervention, the clinical population, and the nurse's intended role in intervention delivery.

Use evidence‐based, manualized CBT‐based interventions that specify core components, session content, delivery procedures, and acceptable adaptations.

Provide structured supervision by clinicians with appropriate CBT expertise and assess nurses' competence before and during intervention delivery.

Establish explicit procedures for monitoring and reporting intervention fidelity, including adherence to the protocol and any deviations or adaptations.

Introduce nurse‐delivered CBT interventions cautiously and with ongoing local evaluation, given the limited and methodologically weak evidence currently available.

Conduct adequately powered controlled studies with longer follow‐up and standardized reporting of nurse preparation, supervision, competency, fidelity, and clinical outcomes.

4.3. Recommendations for Future Research

Future research is needed to strengthen the currently limited and methodologically heterogeneous evidence base on nurse‐delivered CBT interventions. In particular, future studies should employ more rigorous designs with larger sample sizes, longer follow‐up periods, and more standardized reporting of intervention components, nurse preparation, supervision, competency assessment, and intervention fidelity. Additional research is also needed to examine how educational, supervisory, and organizational factors influence implementation and outcomes across psychiatric and chronic care settings. Exploring implementation‐related factors such as feasibility, sustainability, supervision models, and integration within multidisciplinary care environments may further clarify the conditions necessary for consistent, safe implementation in clinical practice.

5. Limitations

The current SR has several limitations that should be considered when interpreting its findings. First, the available evidence base was limited, with only five studies meeting the inclusion criteria, all of which were rated methodologically weak by the EPHPP quality assessment tool. Common methodological limitations included small sample sizes, absence of control groups, high attrition rates, lack of blinding, and limited control of confounding variables. Consequently, the available evidence does not permit firm conclusions regarding the effectiveness of nurse‐delivered CBT interventions, and the findings should be interpreted with caution.

Second, substantial heterogeneity was observed across the included studies in clinical populations, healthcare settings, intervention formats, CBT duration and content, outcome measures, and the structure of nurses' CBT preparation and supervision. This variability precluded quantitative meta‐analysis and necessitated a narrative synthesis, limiting direct comparability across studies and preventing estimation of overall effect sizes. At the same time, this heterogeneity reflects the diverse and context‐dependent ways in which nurse‐delivered CBT interventions are currently implemented across healthcare settings. Finally, the review included only English‐language, full‐text publications and did not include a systematic search of gray literature. Consequently, potentially relevant studies published in other languages or non–peer‐reviewed sources may have been missed, increasing the risk of publication bias and limiting the comprehensiveness of the available evidence.

6. Conclusions

This SR identified limited but growing evidence on CBT interventions delivered by nurses with formal or structured CBT‐related training across psychiatric and chronic care settings. Across the included studies, nurse‐delivered CBT interventions were associated with improvements in psychological symptoms, coping, self‐management, and functional outcomes. However, substantial heterogeneity in study design, intervention structure, training, supervision, and methodological quality limits the ability to draw definitive conclusions regarding effectiveness.

The findings highlight considerable variability in how nurse‐delivered CBT interventions are prepared and implemented across healthcare settings, particularly regarding competency assessment, therapeutic fidelity, and supervision frameworks. Overall, the findings suggest that clearer educational and supervisory structures, as well as more standardized CBT protocols and manualized programs, may support more consistent and transparent implementation of nurse‐delivered CBT interventions in clinical practice and future research.

7. Relevance for Clinical Practice

For healthcare services considering nurse‐delivered CBT interventions, the findings highlight the importance of structured implementation processes, including clearly defined training pathways, ongoing supervision, and competency support mechanisms. Healthcare services may benefit from specifying minimum training expectations, providing supervision by experienced CBT practitioners, and using structured intervention protocols to support consistency and transparency in care delivery.

Funding

The authors have nothing to report.

Disclosure

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.