Becoming confidently competent : a qualitative investigation of training in cognitive functional therapy for persistent low back pain

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY-NC-ND 4.0 https://creativecommons.org/licenses/by-nc-nd/4.0/ Becoming confidently competent : a qualitative investigation of training in cognitive functional therapy for persistent low back pain © 2022 Taylor & Francis Group, LLC. Accepted version (Final draft) Simpson, Phoebe; Holopainen, Riikka; Schütze, Robert; O’Sullivan, Peter; Smith, Anne; Kent, Peter Simpson, P., Holopainen, R., Schütze, R., O’Sullivan, P., Smith, A., & Kent, P. (2024). Becoming confidently competent : a qualitative investigation of training in cognitive functional therapy for persistent low back pain. Physiotherapy Theory and Practice, 40(4), 804-816. https://doi.org/10.1080/09593985.2022.2151333 2024 1 Becoming confidently competent: a qualitative investigation of training 1 in Cognitive Functional Therapy for persistent low back pain 2 3 Ms P. Simpson, BSc(Hons), PT, School of Allied Health, Curtin University, Brand Drive, 4 Bentley, Perth, Western Australia 5 Dr R. Holopainen, PhD, PT, Faculty of Sport and Health Sciences, University of 6 Jyväskylä, Seminaarinkatu 15, 40014 Jyväskylän yliopisto, Finland 7 Dr R. Schütze, PhD, Psych, School of Allied Health, Curtin University, Brand Drive, 8 Bentley, Perth, Western Australia and Multidisciplinary Pain Management Centre, Royal 9 Perth Hospital, Victoria Square, Perth, Western Australia 10 Prof P. O’Sullivan, PhD, PT, School of Allied Health, Curtin University, Brand Drive,, 11 Bentley, Perth, Western Australia and Bodylogic Physiotherapy, 215 Nicholson Rd, 12 Shenton Park, Perth, Western Australia 13 Prof A. Smith, PhD, PT, School of Allied Health, Curtin University, Brand Drive, Bentley, 14 Perth, Western Australia 15 A/Prof P. Kent, PhD, PT, School of Allied Health, Curtin University, Brand Drive, 16 Bentley, Perth, Western Australia 17 Corresponding author: 18 Phoebe Simpson, Curtin University, School of Allied Health 19 Building 408 Brand Drive, Bentley, Western Australia 6102 (AUSTRALIA) 20 Ph: +61429964935 21 Address all correspondence to: [email protected] 22 23 24 2 Becoming confidently competent: a qualitative investigation of training 1 in Cognitive Functional Therapy for persistent low back pain 2 Background: Physiotherapists trained to deliver biopsychosocial interventions 3 for complex musculoskeletal pain problems often report difficulties in confidence 4 and competency at the end of training. Cognitive Functional Therapy is an 5 individualized biopsychosocial intervention initially developed for people with 6 persistent disabling low back pain. Understanding the facilitators and barriers to 7 learning and behavior change for physiotherapists undergoing training to 8 competency in Cognitive Functional Therapy, is important to help inform future 9 training programs. This study aimed to explore the physiotherapists and trainers 10 perceptions of the process of learning to develop competency in Cognitive 11 Functional Therapy. 12 Methods: A cross-sectional qualitative design was used to investigate the 13 training and competency in Cognitive Functional Therapy for persistent low back 14 pain. Eighteen physiotherapists who achieved competency and the two trainers 15 were interviewed. Reflexive thematic analysis was used to analyze the data. 16 Results: Physiotherapists reported undergoing a complex behavior change 17 process during training. Four themes emerged: Pre-training factors, Behavior 18 change process, Physiotherapy culture and context, and Confident competence 19 and beyond. Key components included graduated practice exposure linked to 20 experiential learning with feedback and clear competency guidelines. Pre-training 21 and contextual factors were seen as individual facilitators or barriers. 22 Physiotherapists described learning as an ongoing process, even after 23 competency. 24 Conclusions: This study provides insight into the processes of change 25 physiotherapists undergo to achieve competency in Cognitive Functional 26 Therapy. It highlights facilitators and barriers to competency including 27 physiotherapy culture and the clinical environment. The study also describes 28 important educational components including experiential learning and clinical 29 integration which may be used to inform future post-graduate training. 30 Keywords: biopsychosocial, physiotherapist, training, competency, qualitative 31 3 INTRODUCTION 1 Disability and associated healthcare costs caused by persistent lower back pain (LBP) 2 have dramatically increased over the past 30 years (Dagenais, Caro and Haldeman, 2008; 3 Vos et al, 2015). Purely biomedical approaches have failed to adequately address 4 persistent LBP, so current guidelines recommend a multidimensional biopsychosocial 5 approach due to the significant influence of psychological, social, and behavioral factors 6 on an individual’s pain and disability (Bekkering et al, 2003; Glattacker, Heyduck and 7 Meffert, 2012; Keefe et al, 2004; Koes et al, 2010; Nicholas and George, 2011; Nijs et al, 8 2013). Cognitive Functional Therapy (CFT) is an emerging physiotherapist-led 9 biopsychosocial treatment that has shown promising results in the treatment of 10 musculoskeletal pain conditions compared to other biopsychosocial physiotherapy 11 approaches (Guerrero, Maujean, Campbell and Sterling, 2018). As an individualized 12 treatment approach, CFT aims to coach patients with persistent LBP towards self- 13 management of their condition through: reconceptualizing their pain towards a 14 biopsychosocial perspective, developing confidence to engage in valued functional 15 activities, and adopting healthy lifestyle behaviors (Caneiro et al, 2017; O’Sullivan et al, 16 2018; Vibe Fersum et al, 2013). 17 18 Competency to deliver CFT effectively requires person-centered communication, 19 exploring and addressing physical, lifestyle, psychological, and social barriers to recovery 20 (O’Sullivan et al, 2018). Physiotherapists traditionally have been trained in a biomedical 21 approach to healthcare with a focus on physical impairments (Driver, Oprescu and Lovell, 22 2020; Foster and Delitto, 2011; Synnott et al, 2015; Zangoni and Thomson, 2017). 23 Reviews highlighted physiotherapists often feel insecure and unconfident addressing the 24 psychological domain of an individual’s pain experience (Synnott et al, 2015), even after 25 4 a biopsychosocial training program (Holopainen et al, 2020). Training physiotherapists 1 to deliver CFT requires a significant change in clinical behaviors and professional identity 2 (Cowell et al, 2019). Training in CFT was constructed as a process involving 3 transformative learning mechanisms, with exposure to new experiences and clinical 4 situations which transform skills, behavior, and the way physiotherapists view themselves 5 and the world (Daley and Cervero, 2016; Holopainen et al, 2020). No previous studies 6 have explored processes of learning in a comprehensive CFT training program that also 7 included a formal competency assessment. 8 Understanding the pathway, processes, barriers, and facilitators involved to developing 9 competency in delivering biopsychosocial interventions such as CFT, in a range of 10 physiotherapists, is important to inform future training (Baker et al, 2010; Grimshaw et 11 al, 2012). This study aimed to explore the physiotherapists and trainers perceptions of the 12 facilitators and barriers to learning and behavior change for physiotherapists undergoing 13 training to competency in Cognitive Functional Therapy. 14 METHODS 15 Design 16 A phenomenologically oriented qualitative study design was used. Our ontological 17 approach was critical realist (Bhaskar, 2004; Gorski, 2013) and epistemological 18 underpinning was contextualism (Tebes, 2005). A qualitative research approach allows 19 for rich exploration of experiences and meaning, thereby making visible the workings of 20 the world in which the observer and observed are situated (Denzin and Lincoln, 2017; 21 Tong, Sainsbury and Craig, 2007). The study was nested within a multi-center 22 randomized controlled trial (RESTORE) across Perth and Sydney (Australia) (Kent et al, 23 2019). This study was approved by Curtin University Ethics Committee (HRE2018- 24 0062). 25 5 Participants 1 Physiotherapists ranged from 3 to 25 years of clinical experience. Eleven of the 2 physiotherapists were male and seven females. Before training, all physiotherapists stated 3 that they tried to incorporate a biopsychosocial approach to treat patients with disabling 4 low back pain. However, they felt they lacked skills, which motivated them to join the 5 training program. All 18 physiotherapists who achieved competency to deliver CFT were 6 invited to participate over email, agreed to participate, and provided written informed 7 consent. Trainers were both Specialist Musculoskeletal Physiotherapists with 34 and 17 8 years of clinical experience. 9 Intervention, training, and competency 10 The CFT intervention is a physiotherapist-led individualized biopsychosocial approach 11 to people with persistent disabling lower back pain that aims to identify and target 12 unhelpful beliefs, emotions, and behaviors that act as a barrier to recovery and train 13 people towards self-management. This training program has evolved through an iterative 14 process of trialing different ways of creating behavior change in physiotherapists in other 15 CFT training, focusing on transformative and experiential learning processes through 16 workshops and practice (Bérubé et al, 2017). The training is described in Figure 1. 17 Data collection 18 The first author, a clinical physiotherapist and PhD candidate, conducted all the 19 interviews. The first author had no training or prior exposure to CFT. No relationship was 20 established before the study commencement or interviews, between the first author and 21 any of the participant physiotherapists. A semi-structured interview guide 22 (Supplementary Material 2) was developed , based on previous research of difficulties 23 physiotherapists had reported with learning and using a biopsychosocial approach 24 (Kallio, Pietilä, Johnson and Kangasniemi, 2016). Interviews were held in person for the 25 6 Perth-based physiotherapists and the trainers. For the Sydney physiotherapists, interviews 1 were performed via Skype (Microsoft, 2018) to ensure conversational nuances could still 2 be relayed and rapport built (Gray, Wong-Wylie, Rempel and Cook, 2020). Interviews 3 were conducted in an iterative approach; whereby new findings were investigated further 4 in subsequent interviews. No repeat interviews were carried out. Being a physiotherapist, 5 the interviewer had a level of shared meaning with the participants, which was evident in 6 non-verbal communication, such as nodding or not needing explanations for common 7 acronyms during interviews However, the physiotherapist did not have exposure to or 8 training in CFT and was not part of the training team, which allowed the participants to 9 open up about their experiences. Audio data was recorded using an electronic voice 10 recorder. Interviews ranged from 45 minutes to 1 hour 48 minutes. Eighteen 11 physiotherapists were interviewed. Interviews were conducted within 1 month after 12 achieving competency. Trainers were interviewed immediately after all physiotherapists. 13 Data processing 14 Audio files were transcribed verbatim using Temi (Rev.com, Austin TX, USA) and 15 NVIVO Transcription (QSR International Pty Ltd, 2019). Data was entered into 16 MAXQDA (VERBI Software, 2020), anonymized, and stored on a password-protected 17 university server. 18 Data analysis 19 To gain insights into the learning process from both trainer and physiotherapist 20 perspectives, their experiences were studied using reflexive thematic analysis (Clarke and 21 Braun, 2016). This approach allows for a rich description and analysis of patterns of 22 meaning within the data (Braun and Clarke, 2006, 2019). An inductive approach was 23 used, with no prior themes or frameworks being applied to the data (Braun and Clarke, 24 2006, 2019). MAXQDA, was used to manage the data analysis. 25 7 Initial data familiarization via reading and making notes on the content of the data, key 1 metaphors and language used was performed (Braun and Clarke, 2006). The data were 2 subsequently coded, grouped into categories and initial themes generated (Braun and 3 Clarke, 2006). Refinement and naming of themes occurred in an iterative approach as 4 new patterns in the data emerged. The first author coded the entire dataset, as reflexive 5 thematic analysis foregrounds researcher subjectivity. Therefore, understanding and 6 meaning-making can be interpreted within the reflexive lens of a single author (Braun 7 and Clarke, 2019). Another author (RH) collaborated on two transcripts at the beginning 8 of coding to expand the lens of the meaning-making of the coding, rather than confirm 9 coding. All research team members read the themes, subthemes, codes and associated 10 quotes before discussing and finalizing the themes (Connelly, 2016). 11 RESULTS 12 The overarching theme was that of 'learning as a process', which was likened to that of a 13 learner driver (Fig. 2). Physiotherapists first gained foundational knowledge and skills of 14 CFT supported by a driver’s manual. This was followed by tandem driver learning 15 process where the trainer stepped in as needed. As the physiotherapists’ skill and 16 confidence progressed, the trainers support was removed until the learner driver was 17 confidently driving independently. 18 PT5: You start off, [trainer] just treating patients and then you treat them and then you 19 sort of get [trainer] to jump in when you're stuck and that slowly becomes less and less 20 and less. 21 Themes and subthemes are explained below and depicted in Fig. 2 Quotes have been 22 anonymized (PT for physiotherapist and T for trainer). Supplementary Material 3 23 contains further quotes to illustrate the results. 24 25 8 1. Pre-training factors 1 Reflections on the training process highlighted pre-training factors that the 2 physiotherapists brought to the training, which formed the foundation of their learning 3 journey. 4 1.1 Physiotherapists’ attributes 5 Physiotherapist attributes were considered significant in facilitating the change in mindset 6 and behavior toward competency. Willingness to shift beliefs was seen as an important 7 factor to learning CFT by both trainers and physiotherapists alike. Shifting beliefs was 8 seen to require cognitive flexibility and a growth mindset to self-evaluate and change. 9 PT7: There were definitely different levels of growth and I think that it really 10 depends on your own beliefs, and your own willingness to learn and change and 11 confront your own beliefs. 12 Physiotherapists and trainers felt those who were able to self-reflect and accept feedback 13 were quicker to competency. Being empathetic, understanding, and compassionate 14 towards patients were seen as fundamental and many physiotherapists felt that these 15 factors determined whether someone could learn CFT. Ability to communicate, curiosity 16 and openness were seen as attributes that also helped physiotherapists to learn CFT. 17 The trainers felt that the older physiotherapists had a more difficult journey trying to rely 18 less on a ‘toolbox’ they had used for many years and approach patients from a 19 biopsychosocial perspective. 20 T2: I think unlearning is harder than learning… Because it's almost like they had 21 a toolbox, which they couldn't use, and they were asked to develop a new skillset. 22 And when you have been practicing for many years doing one thing it's pretty 23 hard to then adapt that. 24 15 ball into their court so that they can start on that journey of getting to the point 1 where they can start self-managing. 2 There were mixed reviews about the Facebook group. Some physiotherapists found it 3 very positive for accessing resources, as well as sharing and reading other’s reflections 4 on clinical implementation. Others s felt self-reflections were disingenuous. 5 2.6 Clinical integration 6 Practice in their clinical environment between workshop sessions was conveyed by most 7 physiotherapists as helpful to developing communication skills, knowing how hard to 8 push during exposure and behavioral experiments, and reinforcing learnings. 9 PT11: You learn a new skill and then you need time to practice it. Then you come 10 back and then you implement it half as good as you should, and then you need 11 time to practice it. I don't think 96 hours could be done in two months say or a 12 month or as a really intensive course because you need time to develop. 13 Time to practice implementing CFT between workshops was felt to allow for a gradual 14 enculturation of ideas and new beliefs, which was viewed as important by 15 physiotherapists that had come from a biomedical beliefs system. Treating real patients 16 was also viewed as very important to building confidence, as it was through being part of 17 patient transformations that physiotherapists believed in the process and became 18 confident in the process of CFT to improve patient outcomes. 19 As physiotherapists’ confidence in CFT developed, they reported implementing it with 20 patients beyond just those with LBP, which the trainers felt indicated a shift in thinking 21 of musculoskeletal care towards a biopsychosocial approach. Physiotherapists felt that 22 clinical ‘failures’ or interactions that did not go as well as planned were also part of the 23 learning process and helped them to improve their practice. 24 16 PT14: You've got to make mistakes and then go from there. Because it's the 1 mistakes that you learn the most. Like the little things that you miss or things 2 you're not that happy with. 3 3. Physiotherapy culture and context 4 The learning was situated within physiotherapy culture and the clinical environment in 5 which the physiotherapists worked. Each culture and context provided challenges to 6 their learning journey. 7 3.1 Clinical environment 8 The physiotherapists felt that a supportive clinical environment with opportunities to 9 discuss ideas with colleagues and autonomy to book extra time with patients was an 10 important facilitator to learning. 11 PT16: Part of the learning process is you probably do need a little bit more time 12 because you're going to make mistakes. When you pick the wrong behavioral 13 experiments or you push your patient slightly too far or whatever the case may be 14 and then their pain escalates, then you've got to spend time de-escalating their 15 pain and things like that. 16 Privacy in the clinical environment was felt to be very important for exploring 17 psychosocial issues with their clinical patients. Remuneration for time spent with a patient 18 was an unresolved issue for many physiotherapists. As they were generally treating for 19 an hour or more during their learning period (the trial did not pay for non-trial patients), 20 it was difficult to charge patients adequately. 21 3.2 Physiotherapy culture 22 17 CFT was described by the physiotherapists as contrasting with the current culture in 1 health settings which needs fast, simple treatments, operating on dependency and 2 financial driven models. 3 PT9: A lot of clinics practice in a way that you are making clients a little bit more 4 dependent on you then they need to be, rather than encouraging self-efficacy. I 5 think that that fits the financial model of running a physio, a health business. 6 The physiotherapists had received or were anticipating resistance from other 7 physiotherapists and health professionals, on the ideas underpinning CFT. The 8 physiotherapists also described a lack of consistency across physiotherapy, whereby 9 patients received changing messages, varying appointment durations, and conflicting 10 approaches. Physiotherapy ideas which had permeated into other realms of fitness and 11 health presented clinical challenges in educating other health workers. 12 PT2: It's quite similar with a lot of health professionals, they don't believe it. I've 13 spoken to them. They're like, “What are you talking about, no core! What are you 14 talking about, rounded back!” I say, “Wait in five years, you'll see what I'm 15 saying.” 16 4. Confident competence and beyond 17 Achieving competency was viewed as an assessment of a landmark on a continuing 18 journey, not a final destination. 19 4.1 Achieving competency 20 Competency was based on each physiotherapist achieving the required competencies at 21 their pace. The physiotherapists felt at the end of the training that they were now person- 22 centered in their whole approach. They no longer conduct subjective assessments from a 23 rigid deductive approach, and now spend time understanding each patient. They felt they 24 18 had learnt how to integrate the biopsychosocial elements of a person’s pain experience 1 into their management. 2 PT11: I feel like you connect a lot more with the patient and can actually make 3 meaningful change helping them through their life problems rather than it just 4 being a back pain problem, it's like how it impacts a whole life. 5 Physiotherapists felt they now took time to listen and reflectively question their patient’s 6 narratives. Previously, many had given patients the answers or lectured them. At 7 competency, they encouraged patients to find their own solutions with guidance and they 8 realized this was a more effective strategy to change beliefs and behaviors. ‘Rolling with 9 resistance’(Rollnick and Miller, 1995) was considered a new skill attained through 10 training, whereby physiotherapists did not directly contradict what a patient said, rather 11 they investigated further the underlying reason or belief for what the patient had said. 12 The physiotherapists felt they had become confident asking psychosocial questions, 13 providing validation of their patient’s experiences, and calming patients who expressed 14 emotional distress. Creating behavior change in patients was also a fundamental element 15 to competency. The physiotherapists felt that resistant patients need less explanations and 16 more doing. When the ‘doing’ of behavioral experiments did not bring change within a 17 session, the physiotherapists relied on their therapeutic alliance to get patients to stick 18 with the new ways of moving and lifestyle change for long enough that they improved. 19 At competency, physiotherapists were able to plan and structure the management of their 20 patients, were writing significant aspects of patient views and elements of their narrative 21 in their notes and had a clear end point for their patients. 22 Many of the physiotherapists reported a shift to a judicious approach to manual therapy. 23 Within the trial they were not able to use manual therapy. When they did use it outside of 24 the trial, they reported being clear to patients that they were not creating a mechanical 25 19 change in symptoms, rather modulating the patient’s nervous system. The 1 physiotherapists felt competent to deliver simple psychosocial advice from a 2 physiotherapy perspective, such as lifestyle change, advice on stress, sleep, and mood. 3 However, they recognized they were not psychologists and would refer onwards if 4 patients needed further help managing psychological issues. 5 PT16: I'm not trying to be a psychologist. I'm just listening to my patient hearing 6 that some of these things are factors… related to their condition or a factor. 7 Therefore, why shouldn't I address it? I wouldn't expect a psychologist to treat a 8 musculoskeletal condition in the way that the physio would. But I would expect 9 them to be able to understand that exercise is a healthy living strategy and can 10 help with their psychological concerns. 11 4.2 Improved professional confidence 12 The physiotherapists felt a greater sense of professional confidence after achieving 13 competency. Physiotherapists reported a sense of excitement now when dealing with 14 complex patients. As a result, they were being referred more patients within their 15 practices, and felt more able to confidently communicate their clinical findings and 16 management with other healthcare professionals. 17 PT9: It's kind of strengthened my capacity to be kind of a referral source for 18 difficult back pain clients of my colleagues. 19 4.3 Ongoing challenges 20 Although the physiotherapists achieved competency, they felt that practicing CFT would 21 be a continual learning process towards mastery. 22 PT16: When you master something, it happens without you having to think too 23 hard. I wouldn't say that I've mastered it. I would say that I'm competent. There's 24 a big difference between competence and mastery. 25 20 The physiotherapists reported that challenging resistant patients to make 1 behavioral/lifestyle change was still difficult. One physiotherapist felt tactfully referring 2 patients to psychologists was challenging. Managing your own emotions during patient 3 interactions was also reported by some physiotherapists as needing conscious attention. 4 PT7: Managing your own emotions… You need to tune into your own internal 5 dialogue and I think that’s a skill that physios are not naturally good at because 6 we are used to doing, not thinking like that. 7 DISCUSSION 8 Physiotherapists described the process of learning and achieving competency in CFT as 9 one of complex behavior change. Barriers and facilitators were individual for each 10 physiotherapist based on their personal attributes, previous beliefs, practice and skills, 11 and contextual factors, including time and support within their clinical environment. 12 Despite significant barriers to the learning process, all physiotherapists achieved 13 competency and a sense of confidence to work with patients with persistent disabling 14 back pain. This occurred at different time points, highlighting the individual nature of this 15 process. 16 Physiotherapists highlighted the importance of transformative learning through the 17 experiential learning components of training, feedback, self-reflection, and time for 18 practice within the clinical environment. They recognized that shifting practice to a CFT 19 approach required a paradigm shift in how they conceptualized and worked with 20 patients with persistent low back pain. A ‘paradigm shift’ may be both an outcome and 21 a process of transformative learning, and has been expressed similarly by other 22 physiotherapists training in CFT (Holopainen et al, 2020), stratified care (Hsu et al, 23 2019), and person-centered practice (Lawford et al, 2018). Further demonstrating the 24 paradigm shift, these studies reported clinicians applying this approach to other patient 25 21 groups with psychosocial presentations (Cowell et al, 2018; Sanders, Ong, Sowden and 1 Foster, 2014), as in our study. In contrast, implementation post-training for other 2 biopsychosocial interventions has been described by physiotherapists as a ‘tool in the 3 toolbox’ (Kelly et al, 2018), ‘mix and match’ approach (Nielsen, Keefe, Bennell and 4 Jull, 2014), or ‘instinctive’ without use of the complete approach (Hsu et al, 2019). 5 Selective use of components of a new approach is problematic, particularly as often 6 physiotherapists perceive they employ biopsychosocial approaches more than they do 7 (Fritz, Söderbäck, Söderlund and Sandborgh, 2018; Hsu et al, 2019). 8 9 The most influential component in transforming clinical behavior was reported to be 10 experiential learning. This involved ‘graduated practice exposure’ with feedback, 11 involving a physiotherapist undergoing trainer-supervised delivery of CFT care working 12 with a real person with back pain, in a group setting. Physiotherapists have widely 13 reported experiential learning to be fundamental to clinical behavior change (Cowell et 14 al, 2018, 2019; Driver, Lovell and Oprescu, 2020; Lawford et al, 2018; Nielsen, Keefe, 15 Bennell and Jull, 2014; Simpson et al, 2021; Synnott et al, 2016). This was echoed by 16 our physiotherapists, who likened the process of transformative learning to that of their 17 patients, whose thoughts, emotions, and behaviors are challenged through gradual 18 exposure to feared movements during CFT intervention (Caneiro, Bunzli and 19 O'Sullivan, 2021; Caneiro et al, 2017). The physiotherapists and trainers reported this 20 process occurred as the physiotherapists began to identify their own underlying pain 21 beliefs, and challenge their previous behavioral responses (such as getting a patient to 22 lie down when pain escalated), and emotional responses (including stress and fear if a 23 patient’s pain increased). Individualized feedback and self-reflection allowed further 24 transformation of beliefs and skills, as highlighted in other training and behavior change 25 22 literature (Donaghy and Morss, 2000; Eva et al, 2012; Fritz, Söderbäck, Söderlund and 1 Sandborgh, 2018; Lefroy, Watling, Teunissen and Brand, 2015; Winstone, Nash, Parker 2 and Rowntree, 2017). Working with patients with low back pain in front of colleagues 3 and trainers was described by the physiotherapists as important but also unique. It 4 elicited some discomfort, suggesting that the paradigm shift towards a biopsychosocial 5 approach was so great that the physiotherapists felt exposed and vulnerable. 6 7 Other learning components, including resources and observation, were considered 8 valuable, but did not hold the same behavior change effect. This affirms the literature 9 that resources or observation alone are insufficient for the transformation of 10 biopsychosocial knowledge and skills into practice (Holopainen et al, 2020; Nielsen, 11 Keefe, Bennell and Jull, 2014; Richmond et al, 2016; van der Wees et al, 2008). 12 Similarly, while observing trainers delivering care was considered useful, 13 physiotherapists did not feel this alone transformed their learning. In line with other 14 research, physiotherapists valued learning from physiotherapy experts, who were aware 15 how psychosocial issues relate from a physiotherapy perspective, within the constraints 16 of clinical practice (Driver, Lovell and Oprescu, 2020; Monaghan, Adams and 17 Fothergill, 2018). 18 19 Time for clinical integration between the workshops was considered an important 20 facilitator towards competency to allow gradual enculturation of knowledge and beliefs 21 for the physiotherapists. Literature on learning a biopsychosocial approach 22 demonstrates that although shorter training programs may elicit changes in 23 physiotherapist’s attitudes (Domenech et al, 2011; Jacobs et al, 2016; O'Sullivan, 24 O'Sullivan, O'Sullivan and Dankaerts, 2013), whether they change practice behaviors, 25 23 and patient outcomes is unclear (Overmeer, Boersma, Denison and Linton, 2011; 1 Overmeer, Boersma, Main and Linton, 2009; Sandborgh, Asenlof, Lindberg and 2 Denison, 2010; Stevenson, Lewis and Hay, 2006). After 2-day biopsychosocial training 3 programs, physiotherapists have reported feeling overwhelmed with “too much content 4 to digest” (Lawford et al, 2018), and ongoing difficulty with individualizing care (Kelly 5 et al, 2018). Time for clinical integration with transformative learning experiences is an 6 important consideration for any future training aiming to develop competency and 7 successful clinical application of CFT. 8 9 The clinical environment and personal circumstances can inhibit physiotherapists from 10 embedding learnings from a training program (Synnott et al, 2015; Webster-Wright, 11 2009). In our study, physiotherapists perceived time, support from employers and 12 colleagues, difficulties with pushback or conflicting ideas from other clinicians, privacy, 13 autonomy, reimbursement to be barriers. Individually, each physiotherapist in our study 14 had their own personal barriers to overcome to achieve competency, including personal 15 attributes, and previous beliefs. Despite these barriers, our study demonstrates that, with 16 adequate training, physiotherapists from various clinical and personal backgrounds can 17 become competent to deliver CFT. 18 19 The desired outcome of CFT training is to upskill physiotherapists with critical 20 competencies to successfully work with people with chronic pain in the real world 21 (Gruppen, Mangrulkar and Kolars, 2012). Competency-based education has been 22 acknowledged as more effective for skills acquisition in undergraduate physiotherapy 23 (Hush, Nicholas and Dean, 2018) and medicine (Frank et al, 2010; Ten Cate and Billett, 24 2014). However, literature on employing competency-based education in post-graduate 25 24 physiotherapy is limited, where time-based models of training dominate (Devonshire 1 and Nicholas, 2018; Foster and Delitto, 2011; Simpson et al, 2021). Our results show 2 that the physiotherapists and trainers felt training towards competency using a 3 competency checklist to be fundamental to the learning process and assessment. 4 Practical implications 5 It is important that future training supports the paradigm shift and behavior change 6 required for physiotherapists to deliver CFT successfully. Training programs must be 7 multifaceted including didactic, observational, and experiential learning components 8 with mentoring. Competency assessment to ensure behavior change is imperative. Our 9 study's findings on important training factors may help inform other training programs 10 of complex biopsychosocial approaches. 11 Strengths and Limitations 12 Significant reflexive journaling throughout data collection and analysis was undertaken, 13 enhancing trustworthiness of results (Connelly, 2016). This was informed by Braun and 14 Clark’s reflexive thematic analysis (Braun and Clarke, 2019, 2021) and included self- 15 reflection on the researcher’s position and beliefs. Subsequently the researcher aimed to 16 immerse in the data through reading each transcript in full, reflecting on deeper meaning 17 within the text, questioning and making memos, before imagining, wondering, and 18 reflecting again (Braun and Clarke, 2019, 2021). The cross-sectional design with data 19 collection only at the end of the training was a limitation of the study as physiotherapists 20 may have had difficulty remembering early components of the learning process. Social 21 desirability bias may have been present as physiotherapists may not have wanted to report 22 negative findings (Collins, Shattell and Thomas, 2005). To mitigate potential bias, the 23 interviewer was not involved in the training process and made reassurances of 24 confidentiality and impartiality clear to the physiotherapists. The trainers being highly 25