Table 1 Barriers and enablers (including belief statements and sample quotes) of fidelity to the proposed provider training for relevant domains

Beliefs about capabilities

I am confident in my ability to use an algorithm and/or provide a resource to patients without training. (Barrier)

“What you’re proposing doesn’t really sound like it needs much training. Like I think a lot of physicians hopefully already know this and if they’re given an algorithm to follow, it sounds like it should be pretty straightforward.” GP004

2

Optimism

I think the proposed training strategies (including role play, a training manual, and booster sessions) will help to ensure I feel trained in using the intervention as intended. (Enabler)

What do you think about some of these potential strategies for ensuring fidelity related to training?

“I think they’ll work.” GP001

“I think they’re awesome.” DC005

6

“I think they’re all very reasonable…including the role play.” GP002

“I think that [a training manual] would be helpful. Every bit of training is helpful. It’s better that the practitioner has something to review and read before going into it blindly.” DC002

“I think booster sessions would be really good.” DC002

I think this intervention is great and would want to participate in training and delivering this intervention. (Enabler)

“And so I’m looking at this and I think this is phenomenal. Right? And you could follow and see what has changed in your practice and this is where I get all excited about quality improvement because I think it’s phenomenal.” GP001

4

“Having this conversation about research, I’m like excited – like ‘Yes, I want to do this, that would be awesome’.” DC004

Reinforcement

Incentives (e.g., continuing education credits, monetary compensation) would help me to attend training as intended. (Enabler)

“It has to be CME (continuing medical education) accredited. Absolutely. You might get a few people doing it if it’s not, but it’s gotta be CME accredited.” GP001

9

“Well people love CE (continuing education) hours. If there’s any way to get a simple set up for CE to it, that’s always an incentive for people.” DC003

“Honestly, being compensated for time. Because if physicians have to take time away from their practice to do this, you know, you get paid to do work. So being compensated per hour that you spend in [training] would probably increase participation.” GP002

Memory, attention, and decision processes

I will not participate in this training if I do not see the benefit to my clinical practice. (Barrier)

“At the end of the day, there has to be a direct benefit to us as family physicians as to do we…like we all want to provide good care. But either this helps me cut the conversation shorter or helps me get the patient on my side quicker, right? So something has to help me be better than what I’m currently doing.” GP003

2

“I mean my gut is I don’t think I would personally sign up for any kind of training session because I already engage [in other continuing education]. I just don’t have enough time in my schedule to do that, especially where it’s so specific to one type of intervention…just considering the grand scope of what we see in a day.” GP005

Environmental context and resources

Logistical issues (e.g., time, scheduling, location of training and associated expenses) would prevent me from attending training sessions. (Barrier)

[On challenges to attending training sessions]

“It’s just finding time in your private practice. That’s it. Just time management.” DC002

9

“I just don’t have enough time in my schedule to do that [training], especially where it’s like so specific to one type of intervention.” GP005

““It’s difficult to come in and do these sessions. It’s an expense. For me to go back and forth to the capital city, just in gas, if somebody had to stay in a hotel… So the challenge would be to get the rural people into the urban centre where you’re most likely to have these in-person sessions.” DC005

Emotion

Provider burnout is a barrier to attending training for this intervention. (Barrier)

[On challenges to attending training sessions]

“I think it’s provider burnout.” GP004

3

[On attending training sessions]

“It would be very daunting. I would feel overwhelmed by having to commit to extra training in order to use an intervention that’s supposed to either reduce time in my practice or make my quality of care better or improve the outcomes for my patients.” GP005

Family physicians may be offended by being asked to participate in training for an intervention to reduce LBP imaging. (Barrier)

“And I think community physicians then get a bit jaded and they kind of get their backs up like “what do you mean, I don’t know enough about LBP?!”. You know what I mean? It just becomes kind of one more thing that we’re being told that we’re not very good at and we need to get better, which is true – we’re not very good at this. I will be the first to admit it. But in a system that doesn’t support our community family physicians very well, it can come across as being critical and can be taken incorrectly by those physicians I think.” GP001

1

Behavioural regulation

The logistics of training (e.g., length of sessions, flexibility in scheduling, synchronous and asynchronous options) will help clinicians to complete the intervention training. (Enabler)

[On ways to overcome time or scheduling challenges]

“Options. Being able to give a couple different options for people as to when they can attend. So they look at their calendar, these 3 options are out for me but I can make this one. Rather than it’s happening this day at this time. I think being able to give people a little bit of leeway to figure out what time works best.” DC003

8

“You’re going to have to make it very efficient…and I think a little bit of an a la carte, where I can do what I feel like I need to do. … I think you just need a tailored…or maybe multiple sessions so like I can attend the training session, but not attend the role playing session because I feel like I don’t need that one in particular, right?” GP003

[On the ideal training time of a training session]

“I would say no more than 2 h. All together, in one sitting. Any more than that, it’s kind of hard to get people to commit to. So I would say no more than 2 h. You can do it split up, like you could do two 2-h sessions if you felt like that much training was needed, but no more than 2 h at a time.” GP001

“I’ve seen the transportation from face to face to online/web courses. Anything people can do at say 9 pm when they’re home from work, online. I’m looking for convenience. If I can do it online, that’s perfect. This face-to-face stuff and traveling is done. A module, you review it and click – completed, completed, completed. And you can’t finish that section until you’ve read it and check down ‘yes I’ve done it’.” DC002

A training manual (e.g., with charts and visuals, digital version) to review and refer back to on my own time would help me to train for using this intervention. (Enabler)

“But I do like the possibility of having something like a manual that if it’s 8 o’clock on Monday night and I’m just sitting doing work, can I pull that up and just refresh that way? So having a manual but then also sitting in with everybody.” DC003

5

“PDF. I’ll lose the paper. I never have the paper. I basically have, on my desktop computer, a folder for almost everything. Like I said, the moment it becomes not up to date then people will stop using it. So even if it’s a webpage that I could just link to and it allows people to keep it up to date. Because if it’s not up to date, people will just stop using it. A PDF is harder for you to keep distributing, while the web you can just update it.” GP003

The opportunity to meet in-person in a group setting would help me to train for this intervention. (Enabler)

“Well I’m Zoom’ed out. … So the reality is that if and when we can get together more, I think that a group setting in a real, in-person group setting, in a room, I think would be way more beneficial.” DC005

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