Table 3.

Healthcare professionals’ barriers and enablers to the biopsychosocial approach mapped onto the COM-B model and TDF.

Themes	Subthemes	COM-B domains	TDF domains
Micro level
1.1 Healthcare professional knowledge and skills Healthcare professional’s knowledge of psychosocial factors, evidence-based practice and other healthcare disciplines, and their interpersonal and people skills.	1.1.1 Healthcare professionals are aware of the importance of psychosocial factors, but are vague about what those factors are.	Psychological capability	Knowledge
	1.1.2 Lack of knowledge of the levels of evidence & the concept of evidence-based practice.		Knowledge
	1.1.3 The knowledge (or the lack of knowledge) on how to identify psychosocial factors (including the use of questionnaires and instruments for screening); manage psychosocial factors or yellow flags; or the lack of ability to apply the biopsychosocial model.		Knowledge Skills
	1.1.4 Healthcare professionals’ default approach of addressing “biomedical” or “red flags” first (or only), then “psychosocial” or “yellow flags” or “biopsychosocial”.	Psychological capability Reflective motivation	Memory, attention and decision processes
	1.1.5 The ability (or inability) of the healthcare professionals to manage the clinician-patient alliance.	Psychological capability	Skills
	1.1.6 The ability (or inability) to use communication and interpersonal skills (e.g. counselling, explaining, instructing, listening, reassuring, motivating, promoting and selling a management approach).		Skills
	1.1.7 The knowledge (or the lack of knowledge) of what other healthcare professionals do, other treatment options, when and where to refer to.		Knowledge
	1.1.8 The skill (or the lack of skill) to manage and negotiate health beliefs and patients’ expectations.		Skills
	1.1.9 The skill (or the lack of skill) to manage patients’ emotions and reactions.		Skills
	1.1.10 The knowledge of individualized or personalized care.		Knowledge
	1.1.11 The knowledge that to treat chronic pain, it is not about curing it; rather, managing pain.		Knowledge
	1.1.12 The knowledge that the pain score is a means for the patient to communicate a more general suffering; & the skill to identify & modify pain, specific to patients’ aggravating activity or affected behaviour.		Knowledge Skills
1.2 Healthcare professional personal factors Individual factors and arbitrary choices of healthcare professionals: their emotions associated with chronic pain management; beliefs; level of self-awareness with pre-existing clinical habits; desire to learn; the role and professional identity they assumed; qualifications and work experience associated with the use of a biopsychosocial approach in pain care.	1.2.1 Healthcare professionals’ negative emotions associated with the management of chronic pain, psychosocial factors & the use of CPGs & questionnaires.	Automatic motivation	Emotion
	1.2.2 Healthcare professionals may have habits which they subconsciously continue with; or they may consciously not feel a desire to learn; or they may be self-aware, with an ability to reflect on evidence and clinical experience.	Automatic motivation Reflective motivation	Behavioural regulation Intentions Memory, attention and decision processes Reinforcement
	1.2.3 Healthcare professionals consider OR don't consider it their role (including the role to refer on) & scope of practice to use the BPS approach or follow BPS oriented guidelines.	Reflective motivation	Professional role and identity
	1.2.4 Healthcare professionals biomedical or biopsychosocial treatment orientation or professional identity.
	1.2.5 Healthcare professionals helpful OR unhelpful beliefs (including misconceptions) towards the use of a BPS approach or the use of guidelines.		Beliefs about consequences
	1.2.6 Healthcare professionals additional qualifications & relevant work experience associated with the use of a BPS approach.	Psychological capability Reflective motivation	Knowledge Skills Professional role and identity
1.3 Healthcare professional misconceptions of clinical practice guidelines (CPGs) Healthcare professionals may misunderstand guidelines as being too generic, simplistic, prescriptive or lacking in flexibility to account for the necessary individualised management of musculoskeletal pain. The presentation of information on guidelines may be unappealing to learning quickly.	1.3.1 Guideline recommendation(s) perceived as uncertain OR unhelpful.	Reflective motivation	Beliefs about consequences
	1.3.2 Guidelines are perceived as generic OR simplistic OR too mechanistic, prescriptive OR rigid in the management of patients’ musculoskeletal conditions.
	1.3.3 Guidelines are perceived as not providing adequate clinical tools OR perceived as having too many psychosocial questionnaires to choose from.
	1.3.4 Healthcare professionals are generally not inclined to pay attention to CPGs, the presentation of CPGs is not appealing and may be incompatible with healthcare professionals’ way of learning.		Memory, attention and decision processes
	1.3.5 Healthcare professionals are unclear of what “non-specific” means in the non-specific musculoskeletal pain diagnosis in CPGs.	Psychological capability	Knowledge
1.4 Healthcare professional perceptions about patient factors Healthcare professional perceptions and judgments about patient factors may overemphasize the psychological framing of the condition and the negative stereotype of the difficult patient.	1.4.1 Healthcare professionals’ interpretation or judgment of patients’ lack of motivation or ulterior motives.	Reflective motivation	Intentions
	1.4.2 Patients’ biomedical focus or expectations, unhelpful beliefs and attitudes and poor health literacy can impact on their care and clinical management.	Social opportunity	Social influences
	1.4.3 Healthcare professionals’ judgments about patients’ circumstances, including the judgment of patients’ social issues & involvement with a legal case, which may overemphasize the negative stereotype of chronic musculoskeletal pain.	Reflective motivation	Intentions Beliefs about consequences
	1.4.4 Patients’ complexity of clinical presentation prompts the exploration of psychosocial factors or the use of recommendations from CPGs.	Psychological capability	Skills Memory, attention and decision processes
1.5 Healthcare professional perception of time Healthcare professionals perceived there is insufficient time to explore psychosocial factors within a clinical consultation, and the lack of time for learning.	1.5.1 Healthcare professionals perceived that there is insufficient time to explore psychosocial factors within a clinical consultation, and no time to reflect, or read and learn about CPGs.	Physical opportunity Reflective motivation	Environmental context and resources
Meso level
2.1 CPG formulation Guideline development may be unable to account for different categories of patients, patients’ expectations, healthcare professionals’ former knowledge and training, contextual factors and real-world situations.	2.1.1 Guideline care may not be compatible with the concept of delivering individualized care.	Psychological capability Social opportunity	Knowledge Social influences
	2.1.2 Compatibility of guideline care to healthcare professionals’ clinical practice, former knowledge, training, and real-world practice.	Reflective motivation Social opportunity	Beliefs about capabilities Social influences
	2.1.3 The existence of CPGs help to facilitate and coordinate teamwork among healthcare professionals, provided healthcare professionals are familiar with the content.	Social opportunity	Social influences
	2.1.4 Guidelines are a good source of information to patients and contribute to their understanding of evidence-based treatment options.
	2.1.5 Guidelines provide up-to-date, useful information and decisional algorithms to help healthcare professionals in their clinical decision making and navigate clinical uncertainty.
2.2 Clinical community factors Ready access and availability of an egalitarian interdisciplinary or multidisciplinary team to consult for challenging clinical cases, and whether or not the treatment orientation and communication among professionals within a team is aligned.	2.2.1 Access & availability (or lack thereof) of a clinical support system or network with an efficient communication channel.	Physical opportunity Social opportunity	Environmental context and resources Social influences
	2.2.2 Conflict or alignment between healthcare professionals in the interpretation about what care is required.	Social opportunity Reflective motivation	Social influences Beliefs about consequences
2.3 Funding models Financial barriers such as patients’ lack of health insurance, the lack of funding to incentivise healthcare professionals for their time, effort and qualifications, as well as the funding required to construct models of care appropriate to deliver high value musculoskeletal pain care may impact the feasibility of using the biopsychosocial approach.	2.3.1 The funding model used (i.e. government group insurance, private healthcare insurance, workers’ compensation board, individual out-of-pocket expenses) and the financial feasibility of the BPS approach can encourage or discourage the use of the approach.	Physical opportunity	Environmental context and resources Reinforcement
2.4 Health service provision Work processes such as needing to complete a large amount of administrative work, or performance indicators such as requiring to see many patients or the structure of group therapy sessions may not facilitate the use of a biopsychosocial approach to pain care.	2.4.1 The level of alignment of work processes within organizations to evidence-based methods, or a BPS approach.	Physical opportunity Social opportunity	Environmental context and resources Social influences
2.5 Resourcing issues Lack of resources such as time, specialist services, appointment slots and clinic infrastructure to support the use of a biopsychosocial approach to pain care.	2.5.1 Insufficient time and frequency of consultation, and too much time on long waitlist for referrals to specialist services and investigations are resource-related time barriers to the use of a BPS approach.	Physical opportunity	Environmental context and resources
	2.5.2 The availability (or the lack of) of specialist services, appointment slots, clinic infrastructure and resources (such as educational content and tools) to support a BPS approach.
2.6 Workforce training issues Workforce training issues such as a lack of explicit communication training, counselling and psychosocial competencies in undergraduate and postgraduate training programs.	2.6.1 Lack of counselling/psychosocial training to help healthcare professionals apply a BPS approach.	Physical opportunity	Environmental context and resources
Macro-level
3.1 Health policy Health policy may not prioritise or align to best practice, evidence-based care of musculoskeletal conditions.	3.1.1 The level of political support or attention provided by governments, compensable bodies, professional associations and regulatory boards to provide evidence-based care.	Physical opportunity Social opportunity	Environmental context and resources Social influences
3.2 Organizational factors Organizational factors such as healthcare financing models and regulations within healthcare delivery may not align with high value, person-centred musculoskeletal pain care.	3.2.1 Criterion for the funding set by healthcare systems, insurers or organizations can be compatible or incompatible with the use of a BPS approach.	Physical opportunity Social opportunity	Environmental context and resources Social influences
	3.2.2 Regulations within healthcare systems or workplace culture may promote or obstruct the use of a BPS approach.
3.3 Social factors Social factors such as the persistence and dominance of the biomedical paradigm in healthcare professions and systems, and stigma towards psychological services.	3.3.1 The persistence of a biomedical culture in healthcare professions & systems.	Social opportunity	Social influences
	3.3.2 Social stigma towards psychological services.
	3.3.3 The pervasiveness of information spread via mass media may not be aligned to a BPS model of care.

BPS, biopsychosocial; COM-B, Capability Opportunity Motivation-Behaviour; CPGs, Clinical Practice Guidelines; TDF, Theoretical Domains Framework.