Are newly graduated physiotherapists prepared for work rehabilitation practice? A mixed method study

Are newly graduated physiotherapists prepared for work rehabilitation practice? 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A mixed method study Christian Longtin, Quan Nha Hong, Marie-France Coutu, Naz Yagmur Alpdogan, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8594408/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2026 Read the published version in Journal of Occupational Rehabilitation → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: Physiotherapists are frontline providers in supporting the return-to-work process of individuals with musculoskeletal disorders. However, many report feeling unprepared for work rehabilitation following entry-level training. This study explored recent physiotherapy graduates’ perceived preparedness to practice in work rehabilitation and its influencing factors. Materials and Methods: A convergent mixed methods design grounded in a competency-based framework was used. Recent graduates from physiotherapy programs completed a cross-sectional survey rating their perceived preparedness across seven work rehabilitation competencies. Semi-structured individual interviews explored how their training prepared them for work rehabilitation practice. Quantitative data were analyzed descriptively, and interviews were thematically analyzed. Findings were integrated to contextualize preparedness ratings with qualitative insights. Results: Twenty-five recent graduates from various programs completed both the survey and the interview. Perceived preparedness was highest for competencies on person-centered care and collaborative treatment planning, and lowest for psychosocial factors management, collaboration with involved actors, compensation system navigation and return-to-work support. Three overarching themes influenced perceived preparedness: (1) role perceptions in work rehabilitation, (2) enablers such as supportive curriculum elements, (3) challenges including stigma towards injured workers and limited work rehabilitation-specific training. The fourth theme included strategies to improve work rehabilitation training. Conclusions: Recent physiotherapy graduates reported varying levels of perceived preparedness for work rehabilitation, with the lowest ratings associated with managing psychosocial factors, collaborating with involved actors, navigating compensation systems, and supporting return to work. These gaps were linked to limited work rehabilitation training, perceived role ambiguity, and exposure to stigma. Future research should develop strategies to improve work rehabilitation training in physiotherapy programs. Work rehabilitation Physiotherapy Competencies Work preparedness Figures Figure 1 Introduction Work-related musculoskeletal disorders (MSDs) are a leading cause of disability worldwide [ 1 – 3 ]. These conditions are associated with significant social, economic, and healthcare burdens due to prolonged work absences, reduced work productivity, and increased healthcare utilization [ 1 – 3 ]. As frontline providers in musculoskeletal care, physiotherapists are well positioned to support the rehabilitation and return-to-work (RTW) process of individuals affected by work-related MSDs [ 4 ]. However, evidence indicates that physiotherapists struggle with core aspects of work rehabilitation, including RTW support and navigating compensation systems [ 5 – 8 ]. One potential contributor to these challenges is insufficient exposure to work rehabilitation training during entry-level physiotherapy education [ 6 , 9 ]. In a recent curriculum review conducted in five entry-level physiotherapy programs in a Canadian province, we found that work rehabilitation content was only partially integrated into existing curricula, often embedded within courses addressing other topics and receiving minimal dedicated instructional time (median: 5.5 hours) [ 10 ]. Moreover, core work rehabilitation competencies (e.g., navigating compensation systems, RTW planning, etc.) were inconsistently covered across programs [ 10 ]. Educators also reported low student preparedness in these areas and expressed a need for increased educational resources [ 10 ]. While curriculum reviews are valuable for mapping intended learning objectives and formal educational structures[ 11 ], they offer limited insight into the lived experiences of recent graduates and how their training is applied in clinical practice. They do not capture the influence of hidden curriculum on professional development [ 12 ], nor do they account for the variability in clinical exposure during placements and informal learning [ 13 ]. Furthermore, such curriculum reviews rely solely on educators’ own perspectives. To address these limitations, it is essential to explore the perspectives of physiotherapy graduates entering clinical practice. As new clinicians and primary end-users of physiotherapy education, they provide unique insight into how well their training prepared them for work rehabilitation practice and offer a critical lens on its relevance and transferability [ 14 ]. Building on our previous curriculum review [ 10 ], this study aimed to explore recent physiotherapy graduates’ perceived level of preparedness for work rehabilitation practice upon completion of entry-level training. Specifically, our research questions were: To what extent do recent physiotherapy graduates feel prepared to achieve entry-level work rehabilitation competencies upon graduation? What factors influence their perceived preparedness to practice in work rehabilitation and achieve entry-level competencies upon graduation? How do recent graduates navigate perceived preparedness gaps, and what strategies do they recommend to improve work rehabilitation training? Methods Conceptual framework This study was underpinned by a competency-based education framework, which emphasizes the development and demonstration of competencies aligned with professional roles in health professions education [ 15 , 16 ]. In physiotherapy education, such a framework offers a structured lens to assess whether recent graduates feel prepared to support injured workers, by outlining the knowledge, skills, and attitudes expected for entry-level work rehabilitation practice [ 16 , 17 ]. We applied the competency-based education framework using a set of seven physiotherapy competencies related to work rehabilitation (see Table 1 ) [ 10 ]. These competencies, co-developed by our research team with individuals with lived experience and experts in work rehabilitation, include essential aspects of practice that physiotherapists are expected to fulfill when supporting injured workers. These competencies provided a shared reference point to help participants reflect on how their entry-level training prepared them for work rehabilitation practice. Table 1 Entry-to-practice physiotherapy work rehabilitation competency framework Competencies Description Competency 1 (patient-centered care) Use a person-centered approach that fosters trust and supports the worker’s autonomy Competency 2 (psychosocial management) Recognize and address psychosocial needs and barriers related to the person’s work ability Competency 3 (collaborative treatment planning) Partner with the worker in setting, progressing and adapting rehabilitation goals and interventions that reflect their perceptions, needs and values in relation to his/her work ability Competency 4 (work capacity assessment) Discuss job tasks and context with the person and assess their capacity for work Competency 5 (collaboration with involved actors) Communicate and collaborate with relevant actors to coordinate services and to meet the worker’s rehabilitation goals Competency 6 (compensation system navigation) Support the worker in understanding and navigating relevant compensation systems. Competency 7 (return-to-work support) Facilitate a safe, sustainable, and timely return to work in accordance with the perceptions, needs, and values of the worker. Design We employed a convergent mixed methods design (Quan + QUAL) [ 18 ]. We used a quantitative cross-sectional survey to assess recent physiotherapy graduates’ perceived preparedness for each competency. We conducted qualitative interviews to explore the factors shaping these perceptions and to contextualize their preparedness for work rehabilitation practice. A mixed methods approach was justified by the complementary contributions of each component: the quantitative data provided a structured overview of preparedness levels across competencies, while the qualitative data helped explain why some competencies were perceived as more or less developed. Integrating both methods enabled a more comprehensive understanding of recent graduates’ preparedness than either method could have achieved independently. We reported the study findings based on the Mixed Methods Reporting in Rehabilitation and Health Sciences (MMR-RHS) checklist [ 19 ]. Ethical approval for the study was granted by the McGill University Institutional Review Board (21-07-006). Setting This study was conducted in Quebec, Canada, where healthcare is primarily delivered through a publicly funded system. While physiotherapy services are available in the public healthcare system, most physiotherapists involved in the rehabilitation of injured workers with MSDs are employed by private clinics, which operate on a fee-for-service basis, billing either the worker or their insurer. For work-related injuries or occupational diseases, rehabilitation services are funded through a no-fault Workers’ Compensation Board (WCB) administred by the Commission des normes, de l'équité, de la santé et de la sécurité du travail , contingent on meeting eligibility requirements. In this context, legal clinical responsibility (e.g., diagnosis, determining work-relatedness, RTW decisions) rests with the attending physician, who commonly refers workers to physiotherapy for work-related MSDs. For non-work-related conditions, coverage may come from private insurance plans held by the employer and/or employee, depending on the terms and approval of the policy. Private physiotherapy clinics often hire newly graduated physiotherapists who regularly provide care to injured workers covered by the WCB [ 20 ]. They frequently collaborate with physiotherapy technologists (college-level training) and occupational therapists. In Quebec, entry-level physiotherapy programs are offered through five professional Master’s programs and delivered within a university setting. Study sample We recruited a purposive sample of recent physiotherapy graduates between February and May 2025, with a goal of enrolling the first four to eight eligible participants per program to ensure equal representation across all five physiotherapy programs in Quebec. Eligible participants had to 1) have graduated within the previous six months and up to three years prior, 2) be practicing as a physiotherapist in Quebec at the time of the study, and 3) self-declare experience treating patients covered by the WCB. We sought to maximize variation in participants’ sociodemographic characteristics (e.g., gender, age, region of practice), and professional experience (e.g., years of work experience, proportion of caseload involving workers covered by the WCB, year of graduation). A preliminary sample size was informed by factors consistent with the concept of information power [ 21 ]: a moderately broad study aim, a specific and information-rich sample, and interviewer expertise in work rehabilitation as a researcher and practicing physiotherapist (CL). These factors supported the feasibility of obtaining sufficient information power with five participants per program (n = 25). Information power was assessed iteratively throughout data collection. Recruitment We used multiple recruitment strategies. First, we sent an email invitation to recent physiotherapy graduates who had previously consented to be contacted for research from the authors’ database [ 22 ]. Additional recruitment was conducted via targeted social media posts, distribution through each program’s list of recent graduates, and snowball sampling [ 23 ]. After completing an online screening form to confirm eligibility, qualified individuals received study information and provided electronic informed consent. Participants were then asked to complete a sociodemographic questionnaire (e.g., age, gender, clinical experience, caseload, region of practice and setting). Quantitative component Prior to the interview, participants completed an online survey assessing their self-perceived preparedness across the seven work rehabilitation competencies (Appendix 2). The study instructions were presented to the participants. Then, they rated how well their initial physiotherapy training prepared them to meet entry-to-practice levels for each competency using a 4-point Likert scale (“Not at all prepared” to “Fully prepared”). Qualitative component Using a qualitative descriptive approach [ 24 ], we conducted semi-structured individual interviews to explore factors influencing recent physiotherapy graduates’ perceived preparedness for work rehabilitation practice and key competencies. The interview guide included two sections (Appendix 3). The first was structured around the competency framework and aimed to expand on participants’ survey responses, by exploring how their entry-level training prepared them to meet entry-to-practice levels for each competency and to engage in work rehabilitation practice. The first author (CL) reviewed each participant’s responses before the interview to tailor prompts. Participants also discussed challenges and facilitators related to working with injured workers, including those covered by the WCB, as well as aspects of their training that may have influenced their attitudes and beliefs, and preparedness. The second section explored curriculum strengths and gaps, training needs, and suggestions for improvement. Participants were also asked about any additional training undertaken to address these gaps. We piloted the interview guide with one recent graduate, leading to minor revisions to clarify instructions (e.g., the need to reflect on competencies at the time of graduation, and distinguishing between workers covered by the WCB and patients with work disability). The revised guide was piloted in two other interviews and included in the final analysis. All interviews were conducted by the first author (CL) via Microsoft Teams and lasted up to 60 minutes (range: 34–57). Interviews were audio recorded and professionally transcribed. All transcripts were verified for accuracy by two authors (CL, NYA). We sent the interview guide to participants to provide context and encourage reflection in advance of the discussion. Participants were advised to distinguish between common educational components (e.g., classroom-based learning), and individual experiences (e.g., clinical placements) when possible. To promote open and authentic dialogue, they were reassured that all information would remain confidential. Data analysis We analyzed the sociodemographic characteristics and quantitative survey responses using descriptive statistics. We visually analyzed boxplots and scatterplots to explore potential trends in competencies scores across participant characteristics (e.g., gender, university, experience, etc.) Qualitative data were analyzed using thematic analysis following Braun and Clarke method [ 25 , 26 ], supported by NVivo version 15.1. Two authors (CL, NYA) first familiarized themselves with the transcripts and field notes. A hybrid coding approach was used [ 27 ], applying deductive codes based on the competency framework, followed by inductive codes to capture perspectives beyond predefined competencies, enabling for comparison of both predefined and emergent concepts. Codes were also compared across universities to explore potential differences. CL and NYA independently coded the first two transcripts, and met with two qualitative experts (QNH, TW) to refine identified codes and develop a preliminary codebook. Two additional transcripts were independently coded and used to iteratively refine the codebook, after which all transcripts were coded using the finalized version. Half of the transcripts were double-coded, ensuring at least two interviews per program were analyzed by both coders. Coding discrepancies were resolved through consensus. CL, NYA and QNH then organized codes into preliminary themes using thematic maps and tables to explore patterns across the dataset. Candidate themes were reviewed and refined through peer-debriefing meetings with QNH, MFC and TW to ensure coherence and minimize overlap between themes. Reflexivity and transparency were supported through field notes, independent coding, iterative thematic mapping, and peer-debriefing, which together provided a clear trail and enhanced the trustworthiness of the findings [ 28 ]. A positionality statement is presented in Appendix 4. We integrated findings using a joint display that aligned quantitative ratings with qualitative themes for each competency, enabling identification of convergent, divergent, and complementary insights, and providing a more nuanced understanding of graduates’ perceived preparedness for work rehabilitation practice. Results Participants characteristics Twenty-five recent graduates from all five physiotherapy programs participated in this study (Table 2 ). Most participants identified as cisgender women (64%) with a median age of 26 years (range: 23–34). Most worked in metropolitan (40%) or large urban areas (32%). Participants had a median of 15 months (range: 3–27) of work experience with injured workers covered by the WCB, who made up a median of 25% (range: 5–80) of their caseload. Table 2 Characteristics of participants (n = 25) Characteristic Age (median, IQR*) 26 (2) Gender identity, n (%) Cisgender women 16 (64) Cisgender men 9 (36) Universities, n (%) University 1 5 (20) University 2 4 (16) University 3 6 (24) University 4 6 (24) University 5 4 (16) Work experience (months) with injured workers (median, IQR) 15 (11) Percentage of caseload involving workers covered by the WCB (median, IQR) 25 (30) Practice setting, n (%) Primary care in a private setting 25 (100) Region of practice, n (%) Metropolitan area (population 1,000,000 or more) 10 (40) Large urban area (population 100,000 to 999,999) 8 (32) Medium population centre (population 30,000 to 99,999) 5 (20) Small urban area (population 1000 to 29 999) 2 (8) *IQR = interquartile range Perceived preparedness scores across competencies Participants’ ratings of perceived preparedness for each competency are presented in Fig. 1 . Competency 6 received the lowest ratings, with 72% of participants indicating being “not at all” prepared. In contrast, perceptions of preparedness were higher for Competency 1, with 88% of participants reporting being at least “mostly prepared”. No clear patterns were identified across participants’ characteristics (e.g., university, clinical experience, etc.) and competencies. Factors influencing participants’ perceived preparedness We identified three overarching themes that capture factors influencing recent physiotherapy graduates perceived preparedness to practice in work rehabilitation upon graduation (see Table 3 ). The first theme describes how participants’ perceptions of the physiotherapist role in work rehabilitation influenced their preparedness. The second and third themes describe factors that either enabled or challenged preparedness. Table 3 Summary of themes capturing factors influencing physiotherapy graduates’ perceived preparedness Perceived preparedness influenced by Role perceptions • Role clarity related to physical rehabilitation, patient-centered care and RTW support. • Role ambiguity surrounding collaboration with involved actors, navigation of compensation systems and management of psychosocial factors. Enablers • Foundational curriculum aspects supporting preparedness • A supportive practice context • Postgraduate learning to bridge preparedness gaps Challenges • Navigating the complexity and stigma surrounding workers covered by the WCB • Insufficient work rehabilitation-specific content • Limited work rehabilitation-specific experiential learning opportunities Role perceptions influenced participants’ preparedness for work rehabilitation Participants generally reported greater preparedness for competencies that aligned with their perceived role, such as providing physical rehabilitation and patient-centered care (Competencies 1, 3 and 4), and lower preparedness for competencies where role boundaries were unclear, such as navigating compensation systems, communicating with involved actors, and managing psychosocial factors (Competencies 2, 5 and 6). All participants described their role as focused on musculoskeletal care. This role extended beyond physical rehabilitation to include accompanying patients through the RTW process using a collaborative approach (Competencies 1, 3, 4, and 7). “It’s about supporting the patient, adapting treatments, and getting him back to work […]. There’s often a biopsychosocial component […], but it’s more centered on physical health and physical goals.” – P14 Most participants viewed collaboration with physicians, insurers and other health professionals (Competency 5) as an important part of their role, noting that they often acted as the primary clinician coordinating care and identifying referral needs for the injured worker. However, many expressed uncertainties about the scope of their responsibilities in these interactions. “We often have to liaise with the physician […] we’re the main healthcare professional the patient sees. I have to determine if I think this patient might need an occupational therapist, a psychologist, or another professional.” – P23 This ambiguity also applied to their role in navigating compensation systems, particularly the WCB, and collaborating with insurers (Competencies 5 and 6). While many participants viewed patient advocacy and support with system navigation as important parts of their role, others questioned whether these responsibilities fell within their scope. “[…] conflicts with employers, issues with the WCB, or psychosocial problems, like the stress of not returning to work or pressure from the employer, often fall on us […] That’s where I feel it’s outside the scope of physiotherapy.” – P18 Participants also had mixed perceptions about whether managing psychosocial factors fell within the physiotherapist’s role (Competency 2), though all acknowledged their importance. Factors like fear of movement were seen as within their scope of practice, whereas work-related issues (e.g., workplace conflict), and mental health disorders were often viewed as outside their scope. Nonetheless, many noted that in practice, they often became the default clinician managing these concerns given their frequent contact with injured workers. “These patients don’t receive psychological support, but in the end, they see their physiotherapist several times a week, and […] ends up providing that support, even though it’s not necessarily part of our role as described in our training.” – P20 Enablers of perceived preparedness Participants identified several factors that fostered a sense of preparedness. Some of these were directly related to formal education, while others were shaped by early clinical experiences. Foundational curriculum aspects supported preparedness Participants identified foundational aspects of their training that contributed to their perceived preparedness. These included an emphasis on patient-centered care (Competency 1), interprofessional collaboration (Competency 5), and clinical placements. Although not designed specifically for work rehabilitation, these components were perceived as fostering transferable skills and attitudes essential for treating injured workers. Participants frequently noted that the emphasis on patient-centered care in their training, particularly goal-oriented discussions and shared decision-making, enhanced their ability to build therapeutic relationships (Competencies 1 and 3). This was viewed as essential for working with injured workers, who often face complex challenges that require tailored care. “[…] the objectives and expectations were really emphasized, things like SMART goals and having an approach centered on the person’s goals. That’s beneficial in this context.” – P19 Participants mentioned frequent exposure to interprofessional collaboration as supporting preparedness. They noted that multidisciplinary learning opportunities, often involving occupational therapists and physiotherapy technologists, enhanced their understanding of professional roles and fostered readiness for collaborative care (Competency 5). “The [interdisciplinary activities] helped me a lot. The course that explained each profession really helped me […] understanding the definitions, the roles of each profession […]” – P14 However, some participants reflected that these interprofessional activities were mostly situated in public healthcare settings (e.g., hospital) and did not translate to the realities of work rehabilitation, where collaboration with insurers and physicians occurs beyond their immediate clinical setting. Clinical placements were viewed by participants as key aspects of their training that fostered preparedness, especially when they included exposure to workers covered by the WCB, which only occurred in private clinics. When available, participants perceived these experiences as essential for developing competencies such as supporting RTW (Competency 7). “[…] all the possible options for modifying or adjusting the return-to-work process, I feel like I acquired those more through my clinical placements than through the standard curriculum.” – P03 A supportive practice context Most participants reported that the current model of care in private physiotherapy clinics for injured workers covered by the WCB indirectly fostered their preparedness. They explained how higher session frequency (one to three visits per week) and the ability to follow patients over an extended period enabled more sustained care, creating a supportive clinical environment for developing work rehabilitation competencies in early practice. In constrast, participants perceived fee-for-service, out-of-pocket care for non–work-related conditions as offering fewer learning opportunities. This combination of frequent visits and prolonged follow-up was seen by participants as facilitating stronger therapeutic relationships and creating space for continuous learning, reinforcing their sense of preparedness. “We have between 1 to 3 follow-ups per week, which allowed me to ask other physios questions, to go to mentors and say: ‘I’m dealing with this issue in this case, how would you approach it?’”– P6 Postgraduate learning to bridge preparedness gaps To address gaps in preparedness, many participants engaged in professional development, including mentorship, continuing education, and self-directed learning. These efforts were often focused on competencies that received lower preparedness scores (Competencies 2, 5, 6 and 7). Participants unanimously identified access to mentorship and peer support as key enablers of perceived preparedness, by highlighting the importance of learning from more experienced physiotherapists to understand how to navigate the WCB (Competency 6) and clarify professional responsibilities. “[…] I could talk about my WCB cases and discuss them with a colleague who had more experience. They could guide me through all the WCB processes […] I’d say that’s mainly what helped me fill those gaps afterward.” – P4 Participants mentioned that mentorship was instrumental in developing underdeveloped competencies in entry-level training such as collaboration with insurers (Competency 5), RTW support (Competency 7) and management of psychosocial factors (Competency 2). These interactions were seen as fostering confidence and improved clinical reasoning. “Mentorship played a big role early in my career […] for figuring out how to approach addressing psychosocial factors or physical impairments in the context of work. […] It made a big difference when it came to planning for gradual return to work.” – P1 Some participants also engaged in formal continuing education or self-directed learning to target areas they felt underprepared for. Unlike mentorship, which was often used to address work rehabilitation–specific challenges, continuing education helped build broader skills, particularly strategies to manage psychosocial factors (Competency 2). “In the continuing education courses, I received more specific tools on how to manage psychosocial factors […] That would have been very relevant to have during my university training.” – P23 Challenges to perceived preparedness Participants identified factors that undermined their perceived preparedness, arising from gaps in education and the realities of clinical practice. Key challenges included the clinical complexity and stigma surrounding injured workers covered by the WCB, as well as insufficient work rehabilitation-specific content and experiential learning opportunities during entry-level training. Navigating the complexity and stigma surrounding workers covered by the WCB Most recent graduates described some workers covered by the WCB as presenting with more complex psychosocial profiles (Competency 2). They attributed this complexity to factors such as RTW-related distress, fear of reinjury, and job dissatisfaction, which they felt ill-prepared to address. “How do you communicate with someone who is fearful about going back [to work], all the kinesiophobia aspects, the psychosocial side, how do we approach it, and how do we manage their beliefs and the progression? That part is really challenging.”– P17 Participants from all programs perceived that their preparedness was hindered by stigmas surrounding injured workers shaped by negative beliefs and stereotypes, which they encountered within the curriculum and more prominently during clinical placements. These participants described witnessing some supervisors and educators conveying stigmatizing views, portraying injured workers as lacking motivation, exaggerating symptoms, or abusing the system. “We had some professors who, when talking about WCB patients, were always negative. They would say those patients always have poor outcomes, end up with chronic pain, and don’t want to return to work.” – P18 For some participants, they felt that entering the workforce with these preconceived notions hindered their ability to build a therapeutic alliance and lowered their expectations for treatment outcomes, affecting the quality of care. “[…] after my clinical placements, […] I became more skeptical. Is the patient telling me the truth? Are they really injured? So, early in my practice, I didn’t know if I should believe them or not.” – P20 Insufficient work rehabilitation-specific content All participants identified insufficient work rehabilitation-specific content as the most significant challenge undermining their perceived preparedness. While they felt prepared to provide general musculoskeletal care, many emphasized that their training lacked the applied content and specificity required for work rehabilitation practice. “[…] physical stuff is good, but when it comes to specific functional work related, I don't feel like we've ever even had a case study or practiced that.” – P11 This gap was reflected across four interrelated areas including navigating the compensation system (Competency 6), collaborating with involved actors (Competency 5), intervening on psychosocial factors (Competency 2), and supporting the full RTW process (Competency 4 and 7). A key gap identified by participants was the minimal exposure to the WCB during training. Many reported that administrative procedures, patient eligibility and rehabilitation pathways were either briefly mentioned or entirely absent from the curriculum. This lack of training on the WCB left them feeling ill-equipped to support patients and to fulfill their own, often unclear, responsibilities within the system. Several participants noted being unprepared to answer basic questions from patients, such as how to file a claim or request wage compensation. “[…] when I finished school, I had no knowledge about [the WCB]. I really didn’t feel capable of supporting someone. My first WCB cases, the workers had so many questions, and honestly, they already had more answers than I did.” – P25 All participants reported limited training for collaborating with actors involved in work rehabilitation, particularly physicians and insurers. Although communication with these actors was required in clinical practice, participants reported having little exposure during training to their roles and communication norms. Some participants highlighted the unexpected central role of the physician in the compensation process, especially in RTW planning. Several participants were unfamiliar with how to communicate with physicians, such as what information to include and how to phrase recommendations when writing to physicians during monthly follow-ups to renew sick leave certificates. “I was not prepared for the fact that [WCB patients] would be seeing the physician once a month and we'd be […] writing letters to the doctor with recommendations.” – P10 All participants also emphasized a lack of training for collaborating with the insurers’ case managers, noting limited understanding of their roles and responsibilities, which created confusion during communication. “When it comes to case managers, we’re less prepared because we don’t really know what their roles are, their responsibilities aren’t covered during training. […] it’s hard to have a conversation with someone when you don’t fully understand what they do.” – P18 Some participants described how this lack of preparation made it difficult to coordinate care and support RTW planning, particularly in cases involving competing priorities, such as physicians’ recommendations, employers’ demands, and patients’ needs, leaving the participants feeling unsure how to advocate effectively. “[…] figuring out how to navigate our recommendations for accommodations alongside the employer’s demands, and the physician’s perspective, we’re not well prepared. We lack training to juggle all of that to find the optimal solution for the patient […] » – P22 All participants highlighted the psychosocial challenges associated with injured workers. While most participants felt reasonably equipped to identify psychosocial factors, they expressed uncertainty on how to intervene effectively. Some participants described useful training on psychosocial screening tools, but reported lacking strategies to modify treatment plans accordingly. “Where I found it was lacking was intervening. You have your questionnaires you can administer, but what do you do once you have those […] outcome measures? Like how do you change your treatment to better target that?” – P10 Most participants noted that training rarely addressed the psychosocial challenges of work rehabilitation, such as workplace conflicts, job burden, and RTW-related distress. These work-specific factors were seen as distinct from those encountered in general musculoskeletal rehabilitation, requiring skills participants felt they lacked. “I feel like we barely addressed the impact of being off work, the stress of returning […] or even just hating your job. These are issues specific to workers, and I think we barely covered them.” – P25 Their difficulty in addressing these factors was compounded by the role ambiguity described in Theme 1, as participants were unsure whether managing work-related issues fell within their scope of practice. One participant illustrated this uncertainty by describing “walking on eggshells” when navigating these sensitive topics: “I always feel like I’m walking on eggshells when I address [work-related issues]. Just understanding my role when it comes to […] responding to what the patient shares about their relationship with coworkers or their employer […]” – P3 Most participants expressed a lack of preparedness to support the full RTW process, despite feeling confident in managing the initial impairment-focused phase. Recent graduates expressed difficulty to assess work readiness, citing a lack of tools, benchmarks, and training specific to work capacity assessment. They highlighted that their evaluations mirrored general assessments, with little guidance on work-specific considerations. “We didn't learn if there are specific things we should do before clearing a patient to go back to work, if they're ready or not. […] So that area didn't feel as prepared. It's almost like kind of guessing and not knowing if there's a certain standard that should be reached.” – P10 Participants also reported limited training on adapting treatment plans to patients’ work demands, including uncertainty around discharge planning, knowing when to refer to another professional, or tailoring interventions for work reintegration They described limited knowledge regarding RTW planning, including follow-ups frequency during work reintegration and the use of modified or progressive RTW strategies. Several participants were not aware such strategies existed. “I didn't even know that you can go back part-time and that we could make plans with the patient to help them return to work gradually. That was something I had no idea about when I first graduated.” – P10 Limited work rehabilitation-specific experiential learning opportunities Participants highlighted limited experiential learning in work rehabilitation as a major challenge to preparedness. While participants engaged in workshops and simulations, these experiences were consistently reported as poorly aligned with work rehabilitation practice. “It was very rare for the case studies to involve work-related injuries. They were more often about sports injuries.” – P22 Although clinical placements were seen as key to developing work rehabilitation competencies, many participants noted that access to relevant placements was inconsistent and often depended on chance rather than curricular design. Several participants reported having little exposure to injured workers during placements. This variability, combined with a curricular emphasis on theoretical rather than practical content, left participants feeling unprepared to develop key applied skills. “I guess they expect us to learn [the administrative aspects of the WCB] during clinical placements. But in my placements, I didn't have that many WCB patients, and most of them my supervisor took over.” – P11 Strategies to improve work rehabilitation training The fourth theme focused on the strategies proposed by participants to improve work rehabilitation training by addressing gaps in entry-level physiotherapy education. Participants also emphasized the need for curriculum changes to better reflect the realities of working with workers covered by the WCB. A core strategy was to integrate work rehabilitation content more systematically across the curriculum. Most participants suggested incorporating case studies involving injured workers (e.g., RTW planning) in multiple courses and practical assessments. Several participants also advocated for integrating the lived experiences of injured workers into the curriculum to deepen students’ understanding of the impact of stigma and the challenges of navigating the compensation system and RTW processes. “Include patients covered by the WCB and have them speak directly with students about how they experienced the process, how they perceived being targeted by stigma, [...] whether they felt well supported by physiotherapists.” – P8 Some graduates emphasized the importance of promoting stigma awareness and reflective teaching about injured workers. They called for more nuanced discussion of recovery trajectories and greater attention to personal biases to avoid compromising the quality of care. “[…] some awareness-raising around the comments, beliefs, and attitudes we have toward compensated workers. […] but also recognizing our own biases and how those can affect us and the care we provide.” – P4 Participants recommended the use of simulation-based learning, clinical reasoning exercises, and clinical skills workshops tailored to RTW planning, work capacity assessment and collaboration with involved actors, particularly with case managers. “During a clinical reasoning activity, […] we could meet in a small group, and each person would propose a return-to-work plan. We’d then discuss the pros and cons of each, and what justifies our choices […]” – P1 Many participants expressed the need for more training in psychosocial intervention strategies, such as supporting self-management, addressing psychosocial obstacles to recovery and improving communication skills. “Add courses to help us know what to say to patients when they bring up issues, such as stress, problems with their employer, family issues, or fear of movement. What are we supposed to do with them, and what tools do we have?” – P24 Integration of findings We integrated the quantitative and qualitative findings in Table 4 by presenting preparedness scores alongside participants perceived role in work rehabilitation and the factors influencing perceived preparedness for each competency. Participants also identified broader influences on preparedness across competencies, including more sustained care, limited experiential learning and exposure to stigma toward injured workers. Table 4 Joint display of quantitative and qualitative findings Competencies Preparedness scores 1-4 a (median, IQR b ) Perceived role clarity c Factors influencing perceived preparedness Competency 1 (patient-centered care) 3 (0) Clear • Curriculum emphasis on patient-centered care and shared decision-making (+ d ) Competency 2 (psychosocial management) 2 (0) Ambiguous • Continuing education focused on psychosocial factors management (+) • Complex psychosocial profiles of some injured workers (- e ) • Insufficient training on psychosocial intervention strategies (-) Competency 3 (collaborative treatment planning) 3 (1) Clear • Curriculum emphasis on patient-centered care and shared decision-making (+) • Insufficient training: adapting treatment to work-related goals (-) Competency 4 (work capacity assessment 2 (1) Clear • Insufficient training: work capacity assessment (-) Competency 5 (collaboration with involved actors) 2 (2) Ambiguous • Insufficient training: collaborating with health professionals, insurers and physicians (-) Competency 6 (compensation system navigation) 1 (1) Ambiguous • Insufficient training: collaborating with insurers’ case managers (-) • Insufficient training: navigating the compensation system (-) Competency 7 (Return-to-work support) 2 (2) Clear • Insufficient training: supporting the RTW process (-) a 1=Not at all prepared; 4 = Fully prepared b IQR, Interquartile range c Perceived role clarity reflects the extent to which participants perceived each competency as clearly falling within the physiotherapist’s role in work rehabilitation, derived from the thematic analysis d +, enablers of perceived preparedness e -, challenges to perceived preparedness Discussion This study explored recent physiotherapy graduates’ perceived preparedness for work rehabilitation practice following entry-level training, using a competency-based framework. Perceived preparedness varied notably across competencies. Graduates felt most prepared for competencies aligned with their role perceptions, particularly person-centered care (Competency 1) and collaborative treatment planning (Competency 3). These higher ratings were supported by a curriculum emphasis on shared decision-making, possibility for more sustained care, and clinical exposure during placements, when available. In contrast, competencies for which participants reported role ambiguity, such as intervening on psychosocial factors (Competency 2), collaborating with involved actors (Competency 5) and navigating compensation systems (Competency 6), received lower preparedness scores. Similar low scores were reported for work capacity assessment (Competency 4) and RTW support (Competency 7), which they viewed as part of their role, but lacked specific training related to it. These preparedness gaps were linked to limited work rehabilitation-specific content, insufficient experiential learning, and exposure to stigmatizing beliefs about injured workers during training, including clinical placements. Variability in perceived preparedness across competencies may reflect the degree to which these competencies are emphasized in educational frameworks guiding physiotherapy education. Competencies with higher preparedness ratings, including person-centered care and collaborative treatment planning (Competencies 1 and 3), are embedded in the Canadian physiotherapy competency profile [ 29 ]. These competencies are also prioritized across practice areas such as pain management [ 30 ]. A study on implementing a pain management competency profile in Canadian physiotherapy programs found that educators perceived alignment with national standards as a key enabler of curricular integration [ 31 ]. In contrast, work rehabilitation-specific competencies (e.g., RTW support, compensation system navigation), received the lowest preparedness ratings and were described as largely absent from entry-level training. These competencies are also missing from national regulatory frameworks guiding physiotherapy education [ 29 , 32 ]. This is consistent with our curriculum survey showing limited coverage of work rehabilitation across Quebec physiotherapy programs [ 10 ]. As a result, recent graduates described entering practice feeling unprepared for work rehabilitation practice, a challenge also reported in prior studies with physiotherapists [ 5 – 8 ]. The absence of nationally recognized work rehabilitation competencies to guide curriculum may also contribute to the role ambiguity described by participants, as competencies frameworks are known to support professional identity formation [ 33 ]. Together, these findings suggest that integrating work rehabilitation competencies into national frameworks could enhance recent graduates’ readiness for work rehabilitation practice. Participants’ lack of preparedness to intervene on psychosocial factors, despite feeling equipped to identify them, highlight a persistent gap in psychosocial training in physiotherapy education. This distinction between assessment and intervention adds an important nuance to previous literature, which has largely emphasized general difficulties physiotherapists face in integrating psychosocial care [ 34 – 36 ]. Participants identified intervening as the most challenging aspect, especially for work-related issues (e.g., RTW-related distress). These difficulties reflect partial integration of the biopsychosocial approach in entry-level training, where learning to identify psychosocial factors has not been matched with intervention strategies. Some participants questioned whether addressing certain psychosocial factors was within their scope of practice, further complicating intervention efforts. These findings align with a recent systematic review [ 37 ] that identified role ambiguity and limited intervention-focused training as key barriers to the implementation of a biopsychosocial approach in physiotherapy practice. Our results reinforce the need to strengthen psychosocial training by integrating experiential learning opportunities focused on intervention strategies within a work rehabilitation context. Perceived preparedness for work rehabilitation was shaped not only by entry-level training but also by workplace factors and post-graduate learning. Recent graduates emphasized the importance of mentorship and peer support to help them bridge training gaps and build confidence for work rehabilitation practice. These findings align with Billet’s workplace learning framework [ 38 – 40 ], which asserts that learning extends beyond academic settings and is shaped by workplace opportunities, such as mentorship and collaborative environments. Similar results were reported in Canadian [ 41 ] and Australian [ 42 ] studies, where workplace support and mentorship were central to preparedness for private physiotherapy practice. Many participants engaged in continuing education to address important training gaps and to meet the demands of complex cases. This is concordant with a study that identified patient complexity combined with heavy caseloads as the most challenging aspect of transition to physiotherapy practice [ 43 ]. This proactive learning behaviour reflects another core principle of the workplace learning framework: the worker’s responsibility to engage in professional development [ 40 ]. These findings suggest that preparedness for work rehabilitation is a dynamic process that demands a shared commitment from academic programs, employers, and recent graduates [ 44 ]. Our findings highlight the need to explicitly address stigma toward injured workers within physiotherapy education, largely perpetuated through the hidden curriculum [ 12 ]. Participants described exposure to stigmatizing beliefs through educators’ beliefs and, more prominently, during clinical placements where supervisors and workplace norms conveyed negative assumptions about injured workers, an issue well documented in the literature [ 45 , 46 ]. These experiences shaped how recent graduates approached the care of injured workers covered by the WCB. Participants suggested integrating people with lived experience as a strategy to improve training, an approach shown to challenge bias toward individuals with chronic pain in physiotherapy education [ 47 ]. However, such efforts must extend beyond formal curricula to include all actors shaping informal learning (e.g., educators, supervisors and clinical environments). Overall, these findings indicate that enhancing work rehabilitation training may be limited unless stigma embedded within the hidden curriculum is directly addressed. Strength and Limitations This study is the first to explore recent physiotherapy graduates’ perceived preparedness for work rehabilitation practice. The convergent mixed methods design provided deeper insights on work preparedness than prior studies relying solely on interviews [ 41 ] or surveys [ 48 , 49 ]. Equal representation across all physiotherapy programs enhanced the contextual relevance of the findings. Using a competency-based framework anchored participants’ reflections in clearly defined expectations for work rehabilitation practice. This framework also offers a standardized benchmark that could facilitate knowledge translation and replication in other contexts [ 50 ]. Some limitations should be acknowledged. Participants had completed several months of professional practice before participating in the interviews, which may have introduced recall bias. However, this early career experience was necessary for participants to critically appraise their preparedness, informed by the actual demands of work rehabilitation practice. Findings are limited to recent physiotherapy graduates working in private primary care settings in Quebec, with limited representation from rural areas. Although policy and service delivery models vary across jurisdictions [ 8 , 51 ], workers’ compensation systems across Canadian provinces share core features, supporting the potential transferability of these findings. A key limitation is that preparedness was assessed through participants’ self-perceptions, which may not fully reflect actual clinical competence. Implications and Future Research Work rehabilitation competencies, stigma awareness and role clarification should be better supported across educational and clinical settings. A professional development program has been shown to help early-career physiotherapists navigate complex roles during their first year of practice [ 52 ]. A similar approach could be adapted for work rehabilitation through structured mentorship and workplace learning to enhance physiotherapists’ competence, such as engaging with compensation systems. Our findings suggest that the practice context associated with the WCB is not inherently limiting; rather, its impact on preparedness depends on wether recent graduates are supported to navigate both its benefits (e.g., sustained care) and constraints (e.g., role ambiguity, stigma). A competency-based approach that incorporates work rehabilitation competencies could enhance curricular and professional alignment [ 30 ]. Our findings also indicate that developing postgraduate courses may be a timely and relevant way to improve physiotherapists’ preparedness for work rehabilitation, given the constraints of dense curricula and the lack of work-focused continued education in Canada [ 53 ]. Future research should build on these findings by identifying strategies to improve work rehabilitation training in physiotherapy education. An overarching framework such as the Knowledge-to-Action framework [ 54 ] can serve as a useful guide for this process. Findings from the current study, alongside our curriculum survey [ 10 ], contributes to identifying a clear knowledge-to-practice gap [ 54 ]. The next step is to map barriers and facilitators and develop implementation strategies to support change within entry-level education or through continuing education, evaluate the resulting intervention [ 55 ], and assess integration into routine educational practice [ 56 ]. Ultimately, future research should explore whether improving work rehabilitation training translates into better outcomes for injured workers. Conclusion Physiotherapy graduates reported varying levels of perceived preparedness for work rehabilitation practice, with the lowest ratings associated with competencies such as managing psychosocial factors, collaborating with involved actors, navigating compensation systems, and supporting the RTW process. These gaps were linked to limited work rehabilitation-specific content, perceived role ambiguity, and exposure to stigma toward injured workers. Future research should build on these findings to develop strategies to improve work rehabilitation in physiotherapy education. Statements and Declarations Funding: This work was supported by a grant from the Réseau provincial de recherche en adaptation-réadaptation (REPAR) and the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). CL is supported by a postdoctoral scholarship from the Fonds de Recherche du Québec – Santé (FRQS). Competing interests: The authors report no conflicts of interest. Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Christian Longtin, Quan Nha Hong, Naz Yagmur Alpdogan, Marie-France Coutu and Timothy H Wideman. The first draft of the manuscript was written by Christian Longtin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethical approval: Ethical approval for the study was granted by the McGill University Institutional Review Board (21-07-006). Data availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Consent to participate: Written informed consent was obtained from all participants in the study. References Vos T, Lim SS, Abbafati C, et al (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet 396:1204–1222 Macpherson RA, Lane TJ, Collie A, McLeod CB (2018) Age, sex, and the changing disability burden of compensated work-related musculoskeletal disorders in Canada and Australia. BMC Public Health 18:758 Sanon L, Stock S (2021) Les troubles musculo-squelettiques liés Au travail: Un fardeau Humain et économique évitable. 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Supplementary Files SupplementaryMaterial.pdf Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2026 Read the published version in Journal of Occupational Rehabilitation → Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviews received at journal 25 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 14 Jan, 2026 Reviewers invited by journal 14 Jan, 2026 Editor assigned by journal 14 Jan, 2026 Submission checks completed at journal 14 Jan, 2026 First submitted to journal 13 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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10:46:38","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":174669,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8594408/v1/92e1d8fd0b28b4015875a624.html"},{"id":100595957,"identity":"b614b7f8-9cd4-4f2a-bf7e-8ec68c88b7c2","added_by":"auto","created_at":"2026-01-19 13:49:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":495411,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant ratings of perceived preparedness to meet entry-to-practice level for each competency (n=25)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8594408/v1/b57b1318f225a0c87877e0ab.jpg"},{"id":108437895,"identity":"93988de5-e6b0-4a5f-8737-c753baf22497","added_by":"auto","created_at":"2026-05-04 16:04:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":783942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8594408/v1/7e372458-3d34-447c-af93-4bd17d452073.pdf"},{"id":100578455,"identity":"634dfd97-aa04-4827-a649-229480df56ae","added_by":"auto","created_at":"2026-01-19 10:46:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":285591,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8594408/v1/8b16a2bf541cdf6d4bed89e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Are newly graduated physiotherapists prepared for work rehabilitation practice? A mixed method study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWork-related musculoskeletal disorders (MSDs) are a leading cause of disability worldwide [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These conditions are associated with significant social, economic, and healthcare burdens due to prolonged work absences, reduced work productivity, and increased healthcare utilization [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As frontline providers in musculoskeletal care, physiotherapists are well positioned to support the rehabilitation and return-to-work (RTW) process of individuals affected by work-related MSDs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, evidence indicates that physiotherapists struggle with core aspects of work rehabilitation, including RTW support and navigating compensation systems [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne potential contributor to these challenges is insufficient exposure to work rehabilitation training during entry-level physiotherapy education [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In a recent curriculum review conducted in five entry-level physiotherapy programs in a Canadian province, we found that work rehabilitation content was only partially integrated into existing curricula, often embedded within courses addressing other topics and receiving minimal dedicated instructional time (median: 5.5 hours) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, core work rehabilitation competencies (e.g., navigating compensation systems, RTW planning, etc.) were inconsistently covered across programs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Educators also reported low student preparedness in these areas and expressed a need for increased educational resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile curriculum reviews are valuable for mapping intended learning objectives and formal educational structures[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], they offer limited insight into the lived experiences of recent graduates and how their training is applied in clinical practice. They do not capture the influence of hidden curriculum on professional development [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], nor do they account for the variability in clinical exposure during placements and informal learning [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, such curriculum reviews rely solely on educators\u0026rsquo; own perspectives.\u003c/p\u003e \u003cp\u003eTo address these limitations, it is essential to explore the perspectives of physiotherapy graduates entering clinical practice. As new clinicians and primary end-users of physiotherapy education, they provide unique insight into how well their training prepared them for work rehabilitation practice and offer a critical lens on its relevance and transferability [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Building on our previous curriculum review [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], this study aimed to explore recent physiotherapy graduates\u0026rsquo; perceived level of preparedness for work rehabilitation practice upon completion of entry-level training. Specifically, our research questions were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent do recent physiotherapy graduates feel prepared to achieve entry-level work rehabilitation competencies upon graduation?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat factors influence their perceived preparedness to practice in work rehabilitation and achieve entry-level competencies upon graduation?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do recent graduates navigate perceived preparedness gaps, and what strategies do they recommend to improve work rehabilitation training?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eConceptual framework\u003c/h2\u003e \u003cp\u003eThis study was underpinned by a competency-based education framework, which emphasizes the development and demonstration of competencies aligned with professional roles in health professions education [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In physiotherapy education, such a framework offers a structured lens to assess whether recent graduates feel prepared to support injured workers, by outlining the knowledge, skills, and attitudes expected for entry-level work rehabilitation practice [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe applied the competency-based education framework using a set of seven physiotherapy competencies related to work rehabilitation (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These competencies, co-developed by our research team with individuals with lived experience and experts in work rehabilitation, include essential aspects of practice that physiotherapists are expected to fulfill when supporting injured workers. These competencies provided a shared reference point to help participants reflect on how their entry-level training prepared them for work rehabilitation practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEntry-to-practice physiotherapy work rehabilitation competency framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetencies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 1 (patient-centered care)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse a person-centered approach that fosters trust and supports the worker\u0026rsquo;s autonomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 2 (psychosocial management)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecognize and address psychosocial needs and barriers related to the person\u0026rsquo;s work ability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 3 (collaborative treatment planning)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartner with the worker in setting, progressing and adapting rehabilitation goals and interventions that reflect their perceptions, needs and values in relation to his/her work ability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 4 (work capacity assessment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscuss job tasks and context with the person and assess their capacity for work\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 5 (collaboration with involved actors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunicate and collaborate with relevant actors to coordinate services and to meet the worker\u0026rsquo;s rehabilitation goals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 6 (compensation system navigation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupport the worker in understanding and navigating relevant compensation systems.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 7 (return-to-work support)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacilitate a safe, sustainable, and timely return to work in accordance with the perceptions, needs, and values of the worker.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eWe employed a convergent mixed methods design (Quan\u0026thinsp;+\u0026thinsp;QUAL) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We used a quantitative cross-sectional survey to assess recent physiotherapy graduates\u0026rsquo; perceived preparedness for each competency. We conducted qualitative interviews to explore the factors shaping these perceptions and to contextualize their preparedness for work rehabilitation practice. A mixed methods approach was justified by the complementary contributions of each component: the quantitative data provided a structured overview of preparedness levels across competencies, while the qualitative data helped explain why some competencies were perceived as more or less developed. Integrating both methods enabled a more comprehensive understanding of recent graduates\u0026rsquo; preparedness than either method could have achieved independently. We reported the study findings based on the Mixed Methods Reporting in Rehabilitation and Health Sciences (MMR-RHS) checklist [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Ethical approval for the study was granted by the McGill University Institutional Review Board (21-07-006).\u003c/p\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in Quebec, Canada, where healthcare is primarily delivered through a publicly funded system. While physiotherapy services are available in the public healthcare system, most physiotherapists involved in the rehabilitation of injured workers with MSDs are employed by private clinics, which operate on a fee-for-service basis, billing either the worker or their insurer. For work-related injuries or occupational diseases, rehabilitation services are funded through a no-fault Workers\u0026rsquo; Compensation Board (WCB) administred by the \u003cem\u003eCommission des normes, de l'\u0026eacute;quit\u0026eacute;, de la sant\u0026eacute; et de la s\u0026eacute;curit\u0026eacute; du travail\u003c/em\u003e, contingent on meeting eligibility requirements. In this context, legal clinical responsibility (e.g., diagnosis, determining work-relatedness, RTW decisions) rests with the attending physician, who commonly refers workers to physiotherapy for work-related MSDs. For non-work-related conditions, coverage may come from private insurance plans held by the employer and/or employee, depending on the terms and approval of the policy.\u003c/p\u003e \u003cp\u003ePrivate physiotherapy clinics often hire newly graduated physiotherapists who regularly provide care to injured workers covered by the WCB [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. They frequently collaborate with physiotherapy technologists (college-level training) and occupational therapists. In Quebec, entry-level physiotherapy programs are offered through five professional Master\u0026rsquo;s programs and delivered within a university setting.\u003c/p\u003e\n\u003ch3\u003eStudy sample\u003c/h3\u003e\n\u003cp\u003eWe recruited a purposive sample of recent physiotherapy graduates between February and May 2025, with a goal of enrolling the first four to eight eligible participants per program to ensure equal representation across all five physiotherapy programs in Quebec. Eligible participants had to 1) have graduated within the previous six months and up to three years prior, 2) be practicing as a physiotherapist in Quebec at the time of the study, and 3) self-declare experience treating patients covered by the WCB. We sought to maximize variation in participants\u0026rsquo; sociodemographic characteristics (e.g., gender, age, region of practice), and professional experience (e.g., years of work experience, proportion of caseload involving workers covered by the WCB, year of graduation). A preliminary sample size was informed by factors consistent with the concept of information power [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]: a moderately broad study aim, a specific and information-rich sample, and interviewer expertise in work rehabilitation as a researcher and practicing physiotherapist (CL). These factors supported the feasibility of obtaining sufficient information power with five participants per program (n\u0026thinsp;=\u0026thinsp;25). Information power was assessed iteratively throughout data collection.\u003c/p\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eWe used multiple recruitment strategies. First, we sent an email invitation to recent physiotherapy graduates who had previously consented to be contacted for research from the authors\u0026rsquo; database [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Additional recruitment was conducted via targeted social media posts, distribution through each program\u0026rsquo;s list of recent graduates, and snowball sampling [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. After completing an online screening form to confirm eligibility, qualified individuals received study information and provided electronic informed consent. Participants were then asked to complete a sociodemographic questionnaire (e.g., age, gender, clinical experience, caseload, region of practice and setting).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative component\u003c/h2\u003e \u003cp\u003ePrior to the interview, participants completed an online survey assessing their self-perceived preparedness across the seven work rehabilitation competencies (Appendix 2). The study instructions were presented to the participants. Then, they rated how well their initial physiotherapy training prepared them to meet entry-to-practice levels for each competency using a 4-point Likert scale (\u0026ldquo;Not at all prepared\u0026rdquo; to \u0026ldquo;Fully prepared\u0026rdquo;).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative component\u003c/h3\u003e\n\u003cp\u003eUsing a qualitative descriptive approach [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], we conducted semi-structured individual interviews to explore factors influencing recent physiotherapy graduates\u0026rsquo; perceived preparedness for work rehabilitation practice and key competencies. The interview guide included two sections (Appendix 3). The first was structured around the competency framework and aimed to expand on participants\u0026rsquo; survey responses, by exploring how their entry-level training prepared them to meet entry-to-practice levels for each competency and to engage in work rehabilitation practice. The first author (CL) reviewed each participant\u0026rsquo;s responses before the interview to tailor prompts. Participants also discussed challenges and facilitators related to working with injured workers, including those covered by the WCB, as well as aspects of their training that may have influenced their attitudes and beliefs, and preparedness. The second section explored curriculum strengths and gaps, training needs, and suggestions for improvement. Participants were also asked about any additional training undertaken to address these gaps.\u003c/p\u003e \u003cp\u003eWe piloted the interview guide with one recent graduate, leading to minor revisions to clarify instructions (e.g., the need to reflect on competencies at the time of graduation, and distinguishing between workers covered by the WCB and patients with work disability). The revised guide was piloted in two other interviews and included in the final analysis. All interviews were conducted by the first author (CL) via Microsoft Teams and lasted up to 60 minutes (range: 34\u0026ndash;57). Interviews were audio recorded and professionally transcribed. All transcripts were verified for accuracy by two authors (CL, NYA).\u003c/p\u003e \u003cp\u003eWe sent the interview guide to participants to provide context and encourage reflection in advance of the discussion. Participants were advised to distinguish between common educational components (e.g., classroom-based learning), and individual experiences (e.g., clinical placements) when possible. To promote open and authentic dialogue, they were reassured that all information would remain confidential.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe analyzed the sociodemographic characteristics and quantitative survey responses using descriptive statistics. We visually analyzed boxplots and scatterplots to explore potential trends in competencies scores across participant characteristics (e.g., gender, university, experience, etc.)\u003c/p\u003e \u003cp\u003eQualitative data were analyzed using thematic analysis following Braun and Clarke method [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], supported by NVivo version 15.1. Two authors (CL, NYA) first familiarized themselves with the transcripts and field notes. A hybrid coding approach was used [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], applying deductive codes based on the competency framework, followed by inductive codes to capture perspectives beyond predefined competencies, enabling for comparison of both predefined and emergent concepts. Codes were also compared across universities to explore potential differences.\u003c/p\u003e \u003cp\u003eCL and NYA independently coded the first two transcripts, and met with two qualitative experts (QNH, TW) to refine identified codes and develop a preliminary codebook. Two additional transcripts were independently coded and used to iteratively refine the codebook, after which all transcripts were coded using the finalized version. Half of the transcripts were double-coded, ensuring at least two interviews per program were analyzed by both coders. Coding discrepancies were resolved through consensus.\u003c/p\u003e \u003cp\u003eCL, NYA and QNH then organized codes into preliminary themes using thematic maps and tables to explore patterns across the dataset. Candidate themes were reviewed and refined through peer-debriefing meetings with QNH, MFC and TW to ensure coherence and minimize overlap between themes. Reflexivity and transparency were supported through field notes, independent coding, iterative thematic mapping, and peer-debriefing, which together provided a clear trail and enhanced the trustworthiness of the findings [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A positionality statement is presented in Appendix 4.\u003c/p\u003e \u003cp\u003eWe integrated findings using a joint display that aligned quantitative ratings with qualitative themes for each competency, enabling identification of convergent, divergent, and complementary insights, and providing a more nuanced understanding of graduates\u0026rsquo; perceived preparedness for work rehabilitation practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipants characteristics\u003c/h2\u003e \u003cp\u003eTwenty-five recent graduates from all five physiotherapy programs participated in this study (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most participants identified as cisgender women (64%) with a median age of 26 years (range: 23\u0026ndash;34). Most worked in metropolitan (40%) or large urban areas (32%). Participants had a median of 15 months (range: 3\u0026ndash;27) of work experience with injured workers covered by the WCB, who made up a median of 25% (range: 5\u0026ndash;80) of their caseload.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (median, IQR*)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender identity, n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCisgender women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCisgender men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork experience (months) with injured workers (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of caseload involving workers covered by the WCB (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice setting, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary care in a private setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion of practice, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan area (population 1,000,000 or more)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge urban area (population 100,000 to 999,999)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium population centre (population 30,000 to 99,999)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall urban area (population 1000 to 29 999)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*IQR\u0026thinsp;=\u0026thinsp;interquartile range\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePerceived preparedness scores across competencies\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; ratings of perceived preparedness for each competency are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Competency 6 received the lowest ratings, with 72% of participants indicating being \u0026ldquo;not at all\u0026rdquo; prepared. In contrast, perceptions of preparedness were higher for Competency 1, with 88% of participants reporting being at least \u0026ldquo;mostly prepared\u0026rdquo;. No clear patterns were identified across participants\u0026rsquo; characteristics (e.g., university, clinical experience, etc.) and competencies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing participants\u0026rsquo; perceived preparedness\u003c/h2\u003e \u003cp\u003eWe identified three overarching themes that capture factors influencing recent physiotherapy graduates perceived preparedness to practice in work rehabilitation upon graduation (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The first theme describes how participants\u0026rsquo; perceptions of the physiotherapist role in work rehabilitation influenced their preparedness. The second and third themes describe factors that either enabled or challenged preparedness.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of themes capturing factors influencing physiotherapy graduates\u0026rsquo; perceived preparedness\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePerceived preparedness influenced by\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eRole perceptions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Role clarity related to physical rehabilitation, patient-centered care and RTW support.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Role ambiguity surrounding collaboration with involved actors, navigation of compensation systems and management of psychosocial factors.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEnablers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Foundational curriculum aspects supporting preparedness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; A supportive practice context\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Postgraduate learning to bridge preparedness gaps\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Navigating the complexity and stigma surrounding workers covered by the WCB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Insufficient work rehabilitation-specific content\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Limited work rehabilitation-specific experiential learning opportunities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRole perceptions influenced participants\u0026rsquo; preparedness for work rehabilitation\u003c/h2\u003e \u003cp\u003eParticipants generally reported greater preparedness for competencies that aligned with their perceived role, such as providing physical rehabilitation and patient-centered care (Competencies 1, 3 and 4), and lower preparedness for competencies where role boundaries were unclear, such as navigating compensation systems, communicating with involved actors, and managing psychosocial factors (Competencies 2, 5 and 6).\u003c/p\u003e \u003cp\u003eAll participants described their role as focused on musculoskeletal care. This role extended beyond physical rehabilitation to include accompanying patients through the RTW process using a collaborative approach (Competencies 1, 3, 4, and 7).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s about supporting the patient, adapting treatments, and getting him back to work [\u0026hellip;]. There\u0026rsquo;s often a biopsychosocial component [\u0026hellip;], but it\u0026rsquo;s more centered on physical health and physical goals.\u0026rdquo; \u0026ndash; P14\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants viewed collaboration with physicians, insurers and other health professionals (Competency 5) as an important part of their role, noting that they often acted as the primary clinician coordinating care and identifying referral needs for the injured worker. However, many expressed uncertainties about the scope of their responsibilities in these interactions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We often have to liaise with the physician [\u0026hellip;] we\u0026rsquo;re the main healthcare professional the patient sees. I have to determine if I think this patient might need an occupational therapist, a psychologist, or another professional.\u0026rdquo; \u0026ndash; P23\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis ambiguity also applied to their role in navigating compensation systems, particularly the WCB, and collaborating with insurers (Competencies 5 and 6). While many participants viewed patient advocacy and support with system navigation as important parts of their role, others questioned whether these responsibilities fell within their scope.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] conflicts with employers, issues with the WCB, or psychosocial problems, like the stress of not returning to work or pressure from the employer, often fall on us [\u0026hellip;] That\u0026rsquo;s where I feel it\u0026rsquo;s outside the scope of physiotherapy.\u0026rdquo; \u0026ndash; P18\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also had mixed perceptions about whether managing psychosocial factors fell within the physiotherapist\u0026rsquo;s role (Competency 2), though all acknowledged their importance. Factors like fear of movement were seen as within their scope of practice, whereas work-related issues (e.g., workplace conflict), and mental health disorders were often viewed as outside their scope. Nonetheless, many noted that in practice, they often became the default clinician managing these concerns given their frequent contact with injured workers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;These patients don\u0026rsquo;t receive psychological support, but in the end, they see their physiotherapist several times a week, and [\u0026hellip;] ends up providing that support, even though it\u0026rsquo;s not necessarily part of our role as described in our training.\u0026rdquo; \u0026ndash; P20\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEnablers of perceived preparedness\u003c/h2\u003e \u003cp\u003eParticipants identified several factors that fostered a sense of preparedness. Some of these were directly related to formal education, while others were shaped by early clinical experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFoundational curriculum aspects supported preparedness\u003c/h2\u003e \u003cp\u003eParticipants identified foundational aspects of their training that contributed to their perceived preparedness. These included an emphasis on patient-centered care (Competency 1), interprofessional collaboration (Competency 5), and clinical placements. Although not designed specifically for work rehabilitation, these components were perceived as fostering transferable skills and attitudes essential for treating injured workers.\u003c/p\u003e \u003cp\u003e Participants frequently noted that the emphasis on patient-centered care in their training, particularly goal-oriented discussions and shared decision-making, enhanced their ability to build therapeutic relationships (Competencies 1 and 3). This was viewed as essential for working with injured workers, who often face complex challenges that require tailored care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] the objectives and expectations were really emphasized, things like SMART goals and having an approach centered on the person\u0026rsquo;s goals. That\u0026rsquo;s beneficial in this context.\u0026rdquo; \u0026ndash; P19\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants mentioned frequent exposure to interprofessional collaboration as supporting preparedness. They noted that multidisciplinary learning opportunities, often involving occupational therapists and physiotherapy technologists, enhanced their understanding of professional roles and fostered readiness for collaborative care (Competency 5).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The [interdisciplinary activities] helped me a lot. The course that explained each profession really helped me [\u0026hellip;] understanding the definitions, the roles of each profession [\u0026hellip;]\u0026rdquo; \u0026ndash; P14\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some participants reflected that these interprofessional activities were mostly situated in public healthcare settings (e.g., hospital) and did not translate to the realities of work rehabilitation, where collaboration with insurers and physicians occurs beyond their immediate clinical setting.\u003c/p\u003e \u003cp\u003eClinical placements were viewed by participants as key aspects of their training that fostered preparedness, especially when they included exposure to workers covered by the WCB, which only occurred in private clinics. When available, participants perceived these experiences as essential for developing competencies such as supporting RTW (Competency 7).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] all the possible options for modifying or adjusting the return-to-work process, I feel like I acquired those more through my clinical placements than through the standard curriculum.\u0026rdquo; \u0026ndash; P03\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eA supportive practice context\u003c/h2\u003e \u003cp\u003eMost participants reported that the current model of care in private physiotherapy clinics for injured workers covered by the WCB indirectly fostered their preparedness. They explained how higher session frequency (one to three visits per week) and the ability to follow patients over an extended period enabled more sustained care, creating a supportive clinical environment for developing work rehabilitation competencies in early practice. In constrast, participants perceived fee-for-service, out-of-pocket care for non\u0026ndash;work-related conditions as offering fewer learning opportunities. This combination of frequent visits and prolonged follow-up was seen by participants as facilitating stronger therapeutic relationships and creating space for continuous learning, reinforcing their sense of preparedness.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have between 1 to 3 follow-ups per week, which allowed me to ask other physios questions, to go to mentors and say: \u0026lsquo;I\u0026rsquo;m dealing with this issue in this case, how would you approach it?\u0026rsquo;\u0026rdquo;\u0026ndash; P6\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePostgraduate learning to bridge preparedness gaps\u003c/h2\u003e \u003cp\u003eTo address gaps in preparedness, many participants engaged in professional development, including mentorship, continuing education, and self-directed learning. These efforts were often focused on competencies that received lower preparedness scores (Competencies 2, 5, 6 and 7).\u003c/p\u003e \u003cp\u003eParticipants unanimously identified access to mentorship and peer support as key enablers of perceived preparedness, by highlighting the importance of learning from more experienced physiotherapists to understand how to navigate the WCB (Competency 6) and clarify professional responsibilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] I could talk about my WCB cases and discuss them with a colleague who had more experience. They could guide me through all the WCB processes [\u0026hellip;] I\u0026rsquo;d say that\u0026rsquo;s mainly what helped me fill those gaps afterward.\u0026rdquo; \u0026ndash; P4\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants mentioned that mentorship was instrumental in developing underdeveloped competencies in entry-level training such as collaboration with insurers (Competency 5), RTW support (Competency 7) and management of psychosocial factors (Competency 2). These interactions were seen as fostering confidence and improved clinical reasoning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Mentorship played a big role early in my career [\u0026hellip;] for figuring out how to approach addressing psychosocial factors or physical impairments in the context of work. [\u0026hellip;] It made a big difference when it came to planning for gradual return to work.\u0026rdquo; \u0026ndash; P1\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants also engaged in formal continuing education or self-directed learning to target areas they felt underprepared for. Unlike mentorship, which was often used to address work rehabilitation\u0026ndash;specific challenges, continuing education helped build broader skills, particularly strategies to manage psychosocial factors (Competency 2).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In the continuing education courses, I received more specific tools on how to manage psychosocial factors [\u0026hellip;] That would have been very relevant to have during my university training.\u0026rdquo; \u0026ndash; P23\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eChallenges to perceived preparedness\u003c/h2\u003e \u003cp\u003eParticipants identified factors that undermined their perceived preparedness, arising from gaps in education and the realities of clinical practice. Key challenges included the clinical complexity and stigma surrounding injured workers covered by the WCB, as well as insufficient work rehabilitation-specific content and experiential learning opportunities during entry-level training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eNavigating the complexity and stigma surrounding workers covered by the WCB\u003c/h2\u003e \u003cp\u003eMost recent graduates described some workers covered by the WCB as presenting with more complex psychosocial profiles (Competency 2). They attributed this complexity to factors such as RTW-related distress, fear of reinjury, and job dissatisfaction, which they felt ill-prepared to address.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;How do you communicate with someone who is fearful about going back [to work], all the kinesiophobia aspects, the psychosocial side, how do we approach it, and how do we manage their beliefs and the progression? That part is really challenging.\u0026rdquo;\u0026ndash; P17\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants from all programs perceived that their preparedness was hindered by stigmas surrounding injured workers shaped by negative beliefs and stereotypes, which they encountered within the curriculum and more prominently during clinical placements. These participants described witnessing some supervisors and educators conveying stigmatizing views, portraying injured workers as lacking motivation, exaggerating symptoms, or abusing the system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We had some professors who, when talking about WCB patients, were always negative. They would say those patients always have poor outcomes, end up with chronic pain, and don\u0026rsquo;t want to return to work.\u0026rdquo; \u0026ndash; P18\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor some participants, they felt that entering the workforce with these preconceived notions hindered their ability to build a therapeutic alliance and lowered their expectations for treatment outcomes, affecting the quality of care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] after my clinical placements, [\u0026hellip;] I became more skeptical. Is the patient telling me the truth? Are they really injured? So, early in my practice, I didn\u0026rsquo;t know if I should believe them or not.\u0026rdquo; \u0026ndash; P20\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInsufficient work rehabilitation-specific content\u003c/h2\u003e \u003cp\u003eAll participants identified insufficient work rehabilitation-specific content as the most significant challenge undermining their perceived preparedness. While they felt prepared to provide general musculoskeletal care, many emphasized that their training lacked the applied content and specificity required for work rehabilitation practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] physical stuff is good, but when it comes to specific functional work related, I don't feel like we've ever even had a case study or practiced that.\u0026rdquo; \u0026ndash; P11\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis gap was reflected across four interrelated areas including navigating the compensation system (Competency 6), collaborating with involved actors (Competency 5), intervening on psychosocial factors (Competency 2), and supporting the full RTW process (Competency 4 and 7).\u003c/p\u003e \u003cp\u003e A key gap identified by participants was the minimal exposure to the WCB during training. Many reported that administrative procedures, patient eligibility and rehabilitation pathways were either briefly mentioned or entirely absent from the curriculum. This lack of training on the WCB left them feeling ill-equipped to support patients and to fulfill their own, often unclear, responsibilities within the system. Several participants noted being unprepared to answer basic questions from patients, such as how to file a claim or request wage compensation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] when I finished school, I had no knowledge about [the WCB]. I really didn\u0026rsquo;t feel capable of supporting someone. My first WCB cases, the workers had so many questions, and honestly, they already had more answers than I did.\u0026rdquo; \u0026ndash; P25\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll participants reported limited training for collaborating with actors involved in work rehabilitation, particularly physicians and insurers. Although communication with these actors was required in clinical practice, participants reported having little exposure during training to their roles and communication norms. Some participants highlighted the unexpected central role of the physician in the compensation process, especially in RTW planning. Several participants were unfamiliar with how to communicate with physicians, such as what information to include and how to phrase recommendations when writing to physicians during monthly follow-ups to renew sick leave certificates.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was not prepared for the fact that [WCB patients] would be seeing the physician once a month and we'd be [\u0026hellip;] writing letters to the doctor with recommendations.\u0026rdquo; \u0026ndash; P10\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll participants also emphasized a lack of training for collaborating with the insurers\u0026rsquo; case managers, noting limited understanding of their roles and responsibilities, which created confusion during communication.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When it comes to case managers, we\u0026rsquo;re less prepared because we don\u0026rsquo;t really know what their roles are, their responsibilities aren\u0026rsquo;t covered during training. [\u0026hellip;] it\u0026rsquo;s hard to have a conversation with someone when you don\u0026rsquo;t fully understand what they do.\u0026rdquo; \u0026ndash; P18\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants described how this lack of preparation made it difficult to coordinate care and support RTW planning, particularly in cases involving competing priorities, such as physicians\u0026rsquo; recommendations, employers\u0026rsquo; demands, and patients\u0026rsquo; needs, leaving the participants feeling unsure how to advocate effectively.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] figuring out how to navigate our recommendations for accommodations alongside the employer\u0026rsquo;s demands, and the physician\u0026rsquo;s perspective, we\u0026rsquo;re not well prepared. We lack training to juggle all of that to find the optimal solution for the patient [\u0026hellip;] \u0026raquo; \u0026ndash; P22\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll participants highlighted the psychosocial challenges associated with injured workers. While most participants felt reasonably equipped to identify psychosocial factors, they expressed uncertainty on how to intervene effectively. Some participants described useful training on psychosocial screening tools, but reported lacking strategies to modify treatment plans accordingly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Where I found it was lacking was intervening. You have your questionnaires you can administer, but what do you do once you have those [\u0026hellip;] outcome measures? Like how do you change your treatment to better target that?\u0026rdquo; \u0026ndash; P10\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants noted that training rarely addressed the psychosocial challenges of work rehabilitation, such as workplace conflicts, job burden, and RTW-related distress. These work-specific factors were seen as distinct from those encountered in general musculoskeletal rehabilitation, requiring skills participants felt they lacked.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I feel like we barely addressed the impact of being off work, the stress of returning [\u0026hellip;] or even just hating your job. These are issues specific to workers, and I think we barely covered them.\u0026rdquo; \u0026ndash; P25\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTheir difficulty in addressing these factors was compounded by the role ambiguity described in Theme 1, as participants were unsure whether managing work-related issues fell within their scope of practice. One participant illustrated this uncertainty by describing \u0026ldquo;walking on eggshells\u0026rdquo; when navigating these sensitive topics:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I always feel like I\u0026rsquo;m walking on eggshells when I address [work-related issues]. Just understanding my role when it comes to [\u0026hellip;] responding to what the patient shares about their relationship with coworkers or their employer [\u0026hellip;]\u0026rdquo; \u0026ndash; P3\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants expressed a lack of preparedness to support the full RTW process, despite feeling confident in managing the initial impairment-focused phase. Recent graduates expressed difficulty to assess work readiness, citing a lack of tools, benchmarks, and training specific to work capacity assessment. They highlighted that their evaluations mirrored general assessments, with little guidance on work-specific considerations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We didn't learn if there are specific things we should do before clearing a patient to go back to work, if they're ready or not. [\u0026hellip;] So that area didn't feel as prepared. It's almost like kind of guessing and not knowing if there's a certain standard that should be reached.\u0026rdquo; \u0026ndash; P10\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants also reported limited training on adapting treatment plans to patients\u0026rsquo; work demands, including uncertainty around discharge planning, knowing when to refer to another professional, or tailoring interventions for work reintegration They described limited knowledge regarding RTW planning, including follow-ups frequency during work reintegration and the use of modified or progressive RTW strategies. Several participants were not aware such strategies existed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn't even know that you can go back part-time and that we could make plans with the patient to help them return to work gradually. That was something I had no idea about when I first graduated.\u0026rdquo; \u0026ndash; P10\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimited work rehabilitation-specific experiential learning opportunities\u003c/h2\u003e \u003cp\u003eParticipants highlighted limited experiential learning in work rehabilitation as a major challenge to preparedness. While participants engaged in workshops and simulations, these experiences were consistently reported as poorly aligned with work rehabilitation practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It was very rare for the case studies to involve work-related injuries. They were more often about sports injuries.\u0026rdquo; \u0026ndash; P22\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough clinical placements were seen as key to developing work rehabilitation competencies, many participants noted that access to relevant placements was inconsistent and often depended on chance rather than curricular design. Several participants reported having little exposure to injured workers during placements. This variability, combined with a curricular emphasis on theoretical rather than practical content, left participants feeling unprepared to develop key applied skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I guess they expect us to learn [the administrative aspects of the WCB] during clinical placements. But in my placements, I didn't have that many WCB patients, and most of them my supervisor took over.\u0026rdquo; \u0026ndash; P11\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to improve work rehabilitation training\u003c/h2\u003e \u003cp\u003eThe fourth theme focused on the strategies proposed by participants to improve work rehabilitation training by addressing gaps in entry-level physiotherapy education. Participants also emphasized the need for curriculum changes to better reflect the realities of working with workers covered by the WCB.\u003c/p\u003e \u003cp\u003eA core strategy was to integrate work rehabilitation content more systematically across the curriculum. Most participants suggested incorporating case studies involving injured workers (e.g., RTW planning) in multiple courses and practical assessments. Several participants also advocated for integrating the lived experiences of injured workers into the curriculum to deepen students\u0026rsquo; understanding of the impact of stigma and the challenges of navigating the compensation system and RTW processes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Include patients covered by the WCB and have them speak directly with students about how they experienced the process, how they perceived being targeted by stigma, [...] whether they felt well supported by physiotherapists.\u0026rdquo; \u0026ndash; P8\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome graduates emphasized the importance of promoting stigma awareness and reflective teaching about injured workers. They called for more nuanced discussion of recovery trajectories and greater attention to personal biases to avoid compromising the quality of care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] some awareness-raising around the comments, beliefs, and attitudes we have toward compensated workers. [\u0026hellip;] but also recognizing our own biases and how those can affect us and the care we provide.\u0026rdquo; \u0026ndash; P4\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants recommended the use of simulation-based learning, clinical reasoning exercises, and clinical skills workshops tailored to RTW planning, work capacity assessment and collaboration with involved actors, particularly with case managers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;During a clinical reasoning activity, [\u0026hellip;] we could meet in a small group, and each person would propose a return-to-work plan. We\u0026rsquo;d then discuss the pros and cons of each, and what justifies our choices [\u0026hellip;]\u0026rdquo; \u0026ndash; P1\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Many participants expressed the need for more training in psychosocial intervention strategies, such as supporting self-management, addressing psychosocial obstacles to recovery and improving communication skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Add courses to help us know what to say to patients when they bring up issues, such as stress, problems with their employer, family issues, or fear of movement. What are we supposed to do with them, and what tools do we have?\u0026rdquo; \u0026ndash; P24\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eIntegration of findings\u003c/h2\u003e \u003cp\u003eWe integrated the quantitative and qualitative findings in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e by presenting preparedness scores alongside participants perceived role in work rehabilitation and the factors influencing perceived preparedness for each competency. Participants also identified broader influences on preparedness across competencies, including more sustained care, limited experiential learning and exposure to stigma toward injured workers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJoint display of quantitative and qualitative findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetencies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreparedness scores 1-4\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(median, IQR\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived role clarity\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFactors influencing perceived preparedness\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 1\u003c/p\u003e \u003cp\u003e(patient-centered care)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Curriculum emphasis on patient-centered care and shared decision-making (+\u003csup\u003ed\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 2 (psychosocial management)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmbiguous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Continuing education focused on psychosocial factors management (+)\u003c/p\u003e \u003cp\u003e\u0026bull; Complex psychosocial profiles of some injured workers (-\u003csup\u003ee\u003c/sup\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Insufficient training on psychosocial intervention strategies (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 3 (collaborative treatment planning)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Curriculum emphasis on patient-centered care and shared decision-making (+)\u003c/p\u003e \u003cp\u003e\u0026bull; Insufficient training: adapting treatment to work-related goals (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 4\u003c/p\u003e \u003cp\u003e(work capacity assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Insufficient training: work capacity assessment (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 5 (collaboration with involved actors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmbiguous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Insufficient training: collaborating with health professionals, insurers and physicians (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 6 (compensation system navigation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmbiguous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Insufficient training: collaborating with insurers\u0026rsquo; case managers (-)\u003c/p\u003e \u003cp\u003e\u0026bull; Insufficient training: navigating the compensation system (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency 7\u003c/p\u003e \u003cp\u003e(Return-to-work support)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Insufficient training: supporting the RTW process (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e1=Not at all prepared; 4\u0026thinsp;=\u0026thinsp;Fully prepared\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003eIQR, Interquartile range\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003ePerceived role clarity reflects the extent to which participants perceived each competency as clearly falling within the physiotherapist\u0026rsquo;s role in work rehabilitation, derived from the thematic analysis\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ed\u003c/sup\u003e+, enablers of perceived preparedness\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ee\u003c/sup\u003e-, challenges to perceived preparedness\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored recent physiotherapy graduates\u0026rsquo; perceived preparedness for work rehabilitation practice following entry-level training, using a competency-based framework. Perceived preparedness varied notably across competencies. Graduates felt most prepared for competencies aligned with their role perceptions, particularly person-centered care (Competency 1) and collaborative treatment planning (Competency 3). These higher ratings were supported by a curriculum emphasis on shared decision-making, possibility for more sustained care, and clinical exposure during placements, when available. In contrast, competencies for which participants reported role ambiguity, such as intervening on psychosocial factors (Competency 2), collaborating with involved actors (Competency 5) and navigating compensation systems (Competency 6), received lower preparedness scores. Similar low scores were reported for work capacity assessment (Competency 4) and RTW support (Competency 7), which they viewed as part of their role, but lacked specific training related to it. These preparedness gaps were linked to limited work rehabilitation-specific content, insufficient experiential learning, and exposure to stigmatizing beliefs about injured workers during training, including clinical placements.\u003c/p\u003e \u003cp\u003eVariability in perceived preparedness across competencies may reflect the degree to which these competencies are emphasized in educational frameworks guiding physiotherapy education. Competencies with higher preparedness ratings, including person-centered care and collaborative treatment planning (Competencies 1 and 3), are embedded in the Canadian physiotherapy competency profile [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These competencies are also prioritized across practice areas such as pain management [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A study on implementing a pain management competency profile in Canadian physiotherapy programs found that educators perceived alignment with national standards as a key enabler of curricular integration [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In contrast, work rehabilitation-specific competencies (e.g., RTW support, compensation system navigation), received the lowest preparedness ratings and were described as largely absent from entry-level training. These competencies are also missing from national regulatory frameworks guiding physiotherapy education [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This is consistent with our curriculum survey showing limited coverage of work rehabilitation across Quebec physiotherapy programs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As a result, recent graduates described entering practice feeling unprepared for work rehabilitation practice, a challenge also reported in prior studies with physiotherapists [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The absence of nationally recognized work rehabilitation competencies to guide curriculum may also contribute to the role ambiguity described by participants, as competencies frameworks are known to support professional identity formation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Together, these findings suggest that integrating work rehabilitation competencies into national frameworks could enhance recent graduates\u0026rsquo; readiness for work rehabilitation practice.\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; lack of preparedness to intervene on psychosocial factors, despite feeling equipped to identify them, highlight a persistent gap in psychosocial training in physiotherapy education. This distinction between assessment and intervention adds an important nuance to previous literature, which has largely emphasized general difficulties physiotherapists face in integrating psychosocial care [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Participants identified intervening as the most challenging aspect, especially for work-related issues (e.g., RTW-related distress). These difficulties reflect partial integration of the biopsychosocial approach in entry-level training, where learning to identify psychosocial factors has not been matched with intervention strategies. Some participants questioned whether addressing certain psychosocial factors was within their scope of practice, further complicating intervention efforts. These findings align with a recent systematic review [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] that identified role ambiguity and limited intervention-focused training as key barriers to the implementation of a biopsychosocial approach in physiotherapy practice. Our results reinforce the need to strengthen psychosocial training by integrating experiential learning opportunities focused on intervention strategies within a work rehabilitation context.\u003c/p\u003e \u003cp\u003ePerceived preparedness for work rehabilitation was shaped not only by entry-level training but also by workplace factors and post-graduate learning. Recent graduates emphasized the importance of mentorship and peer support to help them bridge training gaps and build confidence for work rehabilitation practice. These findings align with Billet\u0026rsquo;s workplace learning framework [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], which asserts that learning extends beyond academic settings and is shaped by workplace opportunities, such as mentorship and collaborative environments. Similar results were reported in Canadian [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and Australian [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] studies, where workplace support and mentorship were central to preparedness for private physiotherapy practice. Many participants engaged in continuing education to address important training gaps and to meet the demands of complex cases. This is concordant with a study that identified patient complexity combined with heavy caseloads as the most challenging aspect of transition to physiotherapy practice [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This proactive learning behaviour reflects another core principle of the workplace learning framework: the worker\u0026rsquo;s responsibility to engage in professional development [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. These findings suggest that preparedness for work rehabilitation is a dynamic process that demands a shared commitment from academic programs, employers, and recent graduates [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings highlight the need to explicitly address stigma toward injured workers within physiotherapy education, largely perpetuated through the hidden curriculum [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Participants described exposure to stigmatizing beliefs through educators\u0026rsquo; beliefs and, more prominently, during clinical placements where supervisors and workplace norms conveyed negative assumptions about injured workers, an issue well documented in the literature [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These experiences shaped how recent graduates approached the care of injured workers covered by the WCB. Participants suggested integrating people with lived experience as a strategy to improve training, an approach shown to challenge bias toward individuals with chronic pain in physiotherapy education [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. However, such efforts must extend beyond formal curricula to include all actors shaping informal learning (e.g., educators, supervisors and clinical environments). Overall, these findings indicate that enhancing work rehabilitation training may be limited unless stigma embedded within the hidden curriculum is directly addressed.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eStrength and Limitations\u003c/h2\u003e \u003cp\u003eThis study is the first to explore recent physiotherapy graduates\u0026rsquo; perceived preparedness for work rehabilitation practice. The convergent mixed methods design provided deeper insights on work preparedness than prior studies relying solely on interviews [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] or surveys [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Equal representation across all physiotherapy programs enhanced the contextual relevance of the findings. Using a competency-based framework anchored participants\u0026rsquo; reflections in clearly defined expectations for work rehabilitation practice. This framework also offers a standardized benchmark that could facilitate knowledge translation and replication in other contexts [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome limitations should be acknowledged. Participants had completed several months of professional practice before participating in the interviews, which may have introduced recall bias. However, this early career experience was necessary for participants to critically appraise their preparedness, informed by the actual demands of work rehabilitation practice. Findings are limited to recent physiotherapy graduates working in private primary care settings in Quebec, with limited representation from rural areas. Although policy and service delivery models vary across jurisdictions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], workers\u0026rsquo; compensation systems across Canadian provinces share core features, supporting the potential transferability of these findings. A key limitation is that preparedness was assessed through participants\u0026rsquo; self-perceptions, which may not fully reflect actual clinical competence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eImplications and Future Research\u003c/h2\u003e \u003cp\u003eWork rehabilitation competencies, stigma awareness and role clarification should be better supported across educational and clinical settings. A professional development program has been shown to help early-career physiotherapists navigate complex roles during their first year of practice [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. A similar approach could be adapted for work rehabilitation through structured mentorship and workplace learning to enhance physiotherapists\u0026rsquo; competence, such as engaging with compensation systems. Our findings suggest that the practice context associated with the WCB is not inherently limiting; rather, its impact on preparedness depends on wether recent graduates are supported to navigate both its benefits (e.g., sustained care) and constraints (e.g., role ambiguity, stigma). A competency-based approach that incorporates work rehabilitation competencies could enhance curricular and professional alignment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our findings also indicate that developing postgraduate courses may be a timely and relevant way to improve physiotherapists\u0026rsquo; preparedness for work rehabilitation, given the constraints of dense curricula and the lack of work-focused continued education in Canada [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFuture research should build on these findings by identifying strategies to improve work rehabilitation training in physiotherapy education. An overarching framework such as the Knowledge-to-Action framework [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] can serve as a useful guide for this process. Findings from the current study, alongside our curriculum survey [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], contributes to identifying a clear knowledge-to-practice gap [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The next step is to map barriers and facilitators and develop implementation strategies to support change within entry-level education or through continuing education, evaluate the resulting intervention [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], and assess integration into routine educational practice [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Ultimately, future research should explore whether improving work rehabilitation training translates into better outcomes for injured workers.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePhysiotherapy graduates reported varying levels of perceived preparedness for work rehabilitation practice, with the lowest ratings associated with competencies such as managing psychosocial factors, collaborating with involved actors, navigating compensation systems, and supporting the RTW process. These gaps were linked to limited work rehabilitation-specific content, perceived role ambiguity, and exposure to stigma toward injured workers. Future research should build on these findings to develop strategies to improve work rehabilitation in physiotherapy education.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was supported by a grant from the Réseau provincial de recherche en adaptation-réadaptation (REPAR) and the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). CL is supported by a postdoctoral scholarship from the Fonds de Recherche du Québec – Santé (FRQS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Christian Longtin, Quan Nha Hong, Naz Yagmur Alpdogan, Marie-France Coutu and Timothy H Wideman. The first draft of the manuscript was written by Christian Longtin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eEthical approval for the study was granted by the McGill University Institutional Review Board (21-07-006).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003eWritten informed consent was obtained from all participants in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVos T, Lim SS, Abbafati C, et al (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. 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Physical Therapy 101:pzab078\u003c/li\u003e\n\u003cli\u003eStoikov S, Maxwell L, Butler J, Shardlow K, Gooding M, Kuys S (2022) The transition from physiotherapy student to new graduate: are they prepared? Physiotherapy Theory and Practice 38:101\u0026ndash;111\u003c/li\u003e\n\u003cli\u003eSuleman S, Hall M, Bostick G, Paslawski T, Schmitz C, McFarlane L-A (2021) Work readiness in rehabilitation medicine: a qualitative exploration and framework. International Journal of Therapy and Rehabilitation 28:1\u0026ndash;15\u003c/li\u003e\n\u003cli\u003eHudon A, Hunt M, Ehrmann Feldman D (2018) Physiotherapy for injured workers in Canada: are insurers\u0026rsquo; and clinics\u0026rsquo; policies threatening good quality and equity of care? Results of a qualitative study. BMC Health Services Research 18:682\u0026ndash;682\u003c/li\u003e\n\u003cli\u003eKirsh B, Slack T, King CA (2012) The Nature and Impact of Stigma Towards Injured Workers. J Occup Rehabil 22:143\u0026ndash;154\u003c/li\u003e\n\u003cli\u003eLongtin C, Bhanji A, Houston E, et al (2025) Integrating people living with pain into pre-licensure pain education: a novel learning activity for health professional students. Disability and Rehabilitation 1\u0026ndash;19\u003c/li\u003e\n\u003cli\u003eMerga M (2016) Gaps in work readiness of graduate health professionals and impact on early practice: Possibilities for future interprofessional learning. FoHPE 17:14\u0026ndash;29\u003c/li\u003e\n\u003cli\u003eLawton V, Pacey V, Jones TM, Dean CM (2024) The factors affecting work readiness during the transition from university student to physiotherapist in Australia. HESWBL 14:681\u0026ndash;693\u003c/li\u003e\n\u003cli\u003eHudon A, Gervais M-J, Hunt M (2015) The Contribution of Conceptual Frameworks to Knowledge Translation Interventions in Physical Therapy. Physical Therapy 95:630\u0026ndash;639\u003c/li\u003e\n\u003cli\u003eHudon A, MacEachen E, Lippel K (2022) Framing the Care of Injured Workers: An Empirical Four-Jurisdictional Comparison of Workers\u0026rsquo; Compensation Boards\u0026rsquo; Healthcare Policies. Journal of Occupational Rehabilitation 32:170\u0026ndash;189\u003c/li\u003e\n\u003cli\u003eChipchase L, Papinniemi A, Dafny H, Levy T, Evans K (2022) Supporting new graduate physiotherapists in their first year of private practice with a structured professional development program; a qualitative study. Musculoskeletal Science and Practice 57:102498\u003c/li\u003e\n\u003cli\u003eOlivares-Marchant A, Courtois-Schirmer P, Bolduc A, Gonzalez-Bayard L, Pilon \u0026Eacute;, Hudon A (2024) Availability and Content of Work-Focused Care and Work-Related Factors Continuing Education for Canadian Physiotherapists: An Environmental Scan. Physiotherapy Canada e20230032\u003c/li\u003e\n\u003cli\u003eField B, Booth A, Ilott I, Gerrish K (2014) Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implementation Sci 9:172\u003c/li\u003e\n\u003cli\u003eGuerin RJ, Harden SM, Rabin BA, Rohlman DS, Cunningham TR, TePoel MR, Parish M, Glasgow RE (2021) Dissemination and Implementation Science Approaches for Occupational Safety and Health Research: Implications for Advancing Total Worker Health. IJERPH 18:11050\u003c/li\u003e\n\u003cli\u003eTrinkley KE, Glasgow RE, D\u0026rsquo;Mello S, Fort MP, Ford B, Rabin BA (2023) The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings. Implement Sci Commun 4:116\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-occupational-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joor","sideBox":"Learn more about [Journal of Occupational Rehabilitation](https://www.springer.com/journal/10926)","snPcode":"10926","submissionUrl":"https://submission.nature.com/new-submission/10926/3","title":"Journal of Occupational Rehabilitation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Work rehabilitation, Physiotherapy, Competencies, Work preparedness","lastPublishedDoi":"10.21203/rs.3.rs-8594408/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8594408/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003ePhysiotherapists are frontline providers in supporting the return-to-work process of individuals with musculoskeletal disorders. However, many report feeling unprepared for work rehabilitation following entry-level training. This study explored recent physiotherapy graduates’ perceived preparedness to practice in work rehabilitation and its influencing factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003eA convergent mixed methods design grounded in a competency-based framework was used. Recent graduates from physiotherapy programs completed a cross-sectional survey rating their perceived preparedness across seven work rehabilitation competencies. Semi-structured individual interviews explored how their training prepared them for work rehabilitation practice. Quantitative data were analyzed descriptively, and interviews were thematically analyzed. Findings were integrated to contextualize preparedness ratings with qualitative insights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eTwenty-five recent graduates from various programs completed both the survey and the interview. Perceived preparedness was highest for competencies on person-centered care and collaborative treatment planning, and lowest for psychosocial factors management, collaboration with involved actors, compensation system navigation and return-to-work support. Three overarching themes influenced perceived preparedness: (1) role perceptions in work rehabilitation, (2) enablers such as supportive curriculum elements, (3) challenges including stigma towards injured workers and limited work rehabilitation-specific training. The fourth theme included strategies to improve work rehabilitation training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eRecent physiotherapy graduates reported varying levels of perceived preparedness for work rehabilitation, with the lowest ratings associated with managing psychosocial factors, collaborating with involved actors, navigating compensation systems, and supporting return to work. These gaps were linked to limited work rehabilitation training, perceived role ambiguity, and exposure to stigma. Future research should develop strategies to improve work rehabilitation training in physiotherapy programs.\u003c/p\u003e","manuscriptTitle":"Are newly graduated physiotherapists prepared for work rehabilitation practice? A mixed method study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 10:46:33","doi":"10.21203/rs.3.rs-8594408/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T13:21:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T19:04:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T22:55:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327629351964322545475910708102501235224","date":"2026-01-15T18:41:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257616751321796653777920573425161353288","date":"2026-01-15T14:04:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8891694245429196712501521081963098538","date":"2026-01-14T16:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T14:35:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-14T12:59:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-14T12:58:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Occupational Rehabilitation","date":"2026-01-13T16:48:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-occupational-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joor","sideBox":"Learn more about [Journal of Occupational Rehabilitation](https://www.springer.com/journal/10926)","snPcode":"10926","submissionUrl":"https://submission.nature.com/new-submission/10926/3","title":"Journal of Occupational Rehabilitation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bcceb579-0c0c-4e57-b511-f7b4aa0efee8","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:03:31+00:00","versionOfRecord":{"articleIdentity":"rs-8594408","link":"https://doi.org/10.1007/s10926-026-10404-9","journal":{"identity":"journal-of-occupational-rehabilitation","isVorOnly":false,"title":"Journal of Occupational Rehabilitation"},"publishedOn":"2026-04-30 15:58:31","publishedOnDateReadable":"April 30th, 2026"},"versionCreatedAt":"2026-01-19 10:46:33","video":"","vorDoi":"10.1007/s10926-026-10404-9","vorDoiUrl":"https://doi.org/10.1007/s10926-026-10404-9","workflowStages":[]},"version":"v1","identity":"rs-8594408","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8594408","identity":"rs-8594408","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}