1. IntroductionTreatment outcomes in physiotherapy (PT) are influenced by a variety of factors, some of which depend solely on the clinician [1,2]. Modern PT requires the practitioner to make clinical decisions on the basis of a constantly evolving body of knowledge [3]. Self-efficacy, a person’s belief that they are capable of performing a given task, is an important factor linking acquired knowledge to the practical application of skills [4]. People with low self-efficacy about the skills they possess are more likely to avoid professional tasks and are less likely to persist when encountering challenges and impediments [5]. Clinician self-efficacy is considered a predictor of successful performance in many situations [6] and it may serve as an important mediator of successful treatment outcomes [7,8]. Therefore, higher self-efficacy should be one of the ultimate goals of educational programs in PT, and it is important to assess it with validated instruments.The self-efficacy of physiotherapists (PTs) has been examined in several studies [8,9,10,11,12]. Black et al. [8] measured the self-efficacy of 28 third-year PT students after they completed a 4 h motivational interviewing training. Since self-efficacy is situation specific [13], they used a self-developed questionnaire with three close-ended and two open-ended questions to assess students’ confidence in motivating patients to engage in physical activity. Nithman et al. [9] also used a self-developed questionnaire to examine the impact of intensive care unit simulation training on students’ perceived readiness for clinical placements. The questionnaire contained nine questions rated on a 5-point Likert scale and was developed by an expert panel of four university faculty members. However, in all of these studies [8,9,10,11,12], the self-developed scales were not validated, which significantly limits the ability to conclude and make further use of the proposed measurement tools. In contrast to these unvalidated scales, the Physiotherapist Self-Efficacy (PSE) questionnaire (Appendix A) was designed and validated to measure self-efficacy of PT students [14]. The PSE contains 13 items measuring self-efficacy beliefs in three PT clinical domains: musculoskeletal, cardiorespiratory, and neurological. The items of the PSE are rated on a five-point Likert scale indicating the degree of confidence in performing a described task (1 = very little confidence; 5 = a lot of confidence). The methodological quality of the PSE has been examined, and the component structure of the PSE suggests that the self-efficacy of PT students is not general but specific to a clinical domain [14]. Thus, when using the PSE as an outcome measure, the rater must select one of the three clinical domains. The PSE was used by van Lankveld et al. [15] to compare the outcomes of two educational approaches for PT students. They found that self-directed learning and traditional classroom-based learning resulted in equal self-efficacy at the end of the second year. In addition, Campbell et al. [16] conducted a study to investigate the readiness of physiotherapy doctoral students for clinical experiences. The authors concluded that self-efficacy can be used to identify students who need additional supervision during traditional and telemedicine clinical experiences. In contrast to van Lankveld et al. [15], they used a general validated but not domain specific self-efficacy scale [17].Low back pain (LBP) is the most common complaint in musculoskeletal clinical practice and the leading cause of activity limitations and work absence in most countries of the world [18]. Since 1990, the number of years with disability due to LBP has increased by more than 50%, especially in low- and middle-income countries [18,19]. Since clinician self-efficacy may be an important mediator of successful treatment outcomes [7,8] and LBP has unique clinical features and a high prevalence rate, it could be valuable to assess self-efficacy in this specific clinical domain using the PSE.Currently, the PSE is not available in Hebrew and there is no other self-efficacy measurement tool available in Hebrew for PT students or clinicians. Nowadays, it is recognized that items of a measurement to be used in another language and/or culture must not only be well translated linguistically but also culturally adapted to maintain content validity across different cultures [20]. Furthermore, the PSE has only been used to assess self-efficacy in PT students, but not in practicing clinicians. It is important to assess PSE fluctuation over time as clinicians gain additional experience and pursue postgraduate training. Resnik et al. [2] have shown that post-graduate training and certification can lead to better clinical outcomes in treating people with LBP [2]. The common explanation is that the additional clinical knowledge and skills are responsible for this change in outcomes. However, it can also be assumed that a change in the PTs’ self-efficacy may have led to improved outcomes. This assumption highlights the need to assess the self-efficacy of practicing clinicians treating people with LBP.

Therefore, this study aimed to (1) translate and trans-culturally adapt the PSE into Hebrew, (2) adjust the PSE so that it can be used to assess clinicians’ self-efficacy in treating LBP, and (3) assess the construct validity and reliability of the Hebrew version of the PSE.

4. DiscussionsThis study demonstrates the successful trans-cultural adaptation of the adjusted PSE into Hebrew. No particular difficulties were encountered during the translation process, and the translated questionnaire was found to be highly reliable and valid. Furthermore, in this study, we demonstrated a specific adaptation of the PSE, providing the opportunity to assess clinician self-efficacy in treating LBP, which is the most common complaint in musculoskeletal practice [18].The obtained Cronbach’s alpha value of the translated PSE showed excellent internal consistency, indicating that the scale was coherent and homogeneous. Although Cronbach’s alpha values were specific to the particular group of responders and cannot be purely generalized [37], the relatively large sample size in this study, which exceeded COSMIN recommendation [21], may further strengthen the reliability of the translated PSE. The EFA of the translated PSE questionnaire resulted in one extracted factor with eigenvalues > 1, explaining 56.48% of the total variance. This unidimensional structure allowed for a single summated score. All items displayed moderate-to-high loadings, except item 11, which still had a loading above 0.3 and therefore was not removed [33]. These results strengthen the structural validity of the PSE [34,35,36].Since LBP is the most common complaint in musculoskeletal clinical practice and the leading cause of disability and works absence [18], researchers should invest time and effort into better understand this condition and develop effective treatments. To our knowledge, this is the first study to examine clinician self-efficacy in treating LBP. The interpretation of PSE values has not been fully clarified. For example, categorical thresholds have not yet been established. Therefore, we have not been able to interpret the level of PSE values and categorize them as low, moderate, or high. In addition, it is not clear to what extent a change in PSE score represents a meaningful change in clinician self-efficacy despite our calculation of MDC. We therefore recommend that categorical thresholds be established in future studies and that the minimum clinically important difference scores of the PSE be calculated in order to make better use of the instrument in studies and educational settings. Our results showed that age and experience were moderately correlated with PSE scores. This may suggest that repeated exposure to patients with LBP increases clinician self-efficacy. Our findings also showed that PTs working in public or private outpatient clinics had significantly higher PSE scores than PTs working in hospitals. In addition, PTs who worked in an inpatient rehabilitation facility had a significantly lower score compared with PTs who worked in a private outpatient clinic. These results are consistent with Bundara’s assertion that self-efficacy is situation specific and not general [13], as LBP cases are almost exclusively treated in outpatient clinics, but in some cases patients with LBP may also be treated in inpatient rehabilitation facilities. PTs with postgraduate academic education had higher PSE scores than PTs with bachelor’s degrees. However, the difference was not greater than the MDC [34]. This may further emphasize that better clinician self-efficacy in treating patients with LBP is related to specific exposure to such cases. Therefore, postgraduate academic education does not necessarily lead to a meaningful improvement in self-efficacy without the relevant clinical experience.Clinician self-efficacy is thought to lead to better treatment outcomes [7,8]. However, to our knowledge, no study has demonstrated this association specifically while using a validated outcome measure for self-efficacy. We therefore recommend that future studies examine whether higher clinician self-efficacy leads to better treatment outcomes. If such an association will be demonstrated, clinician self-efficacy should serve as an outcome measurement for postgraduate clinical education programs as it is easier to apply in contrast to other means. By using PSE as an assessment tool, postgraduate clinical education programs can be evaluated for their effectiveness in improving the future performance of participating clinicians.As with any study, there are some limitations to note. First, the study consisted exclusively of PTs, and therefore the results can be only generalized to this population and should be taken with caution if applying the PSE to other professions who treat patients with LBP. Second, participants were recruited through social media groups and email lists, which may lead to selection bias and not represent the general Israeli PT population. To overcome this issue, the study sample was larger than the sample recommended by the COSMIN guideline [21]. Finally, in this study, the PSE was adjusted to a specific condition (LBP). This might reduce the applicability of the Hebrew version of the PSE to other clinical conditions.