Authors: Meike Schwinger & Marion Grafe | Submitted: 16th October 2019
This article is currently under peer review.
Background: Historically, clinical education of physiotherapy students in Germany takes place in inpatient settings. Against the background that the majority of graduated physiotherapists work in outpatient settings like private practices, this education structure is no longer viable. Therefore, there is a need to develop models of cooperation between private practice and schools of physiotherapy.
Aim: The aim of this study is to describe options of cooperation between educational institutions and private practices.
Methods: A qualitative interview study was conducted, in which 2 practice owners of a physiotherapy practice and 2 heads of physiotherapy schools were interviewed using a problem-centered interview approach. Textual data was analysed using thematic analysis, to inductively discover and describe relevant themes.
Results: Heads of schools and practice owners share many ideas about learning location cooperation, such as a restriction on the number of students for each practice, the timing of clinical education in private practice at the end of the study program, the need for close cooperation between schools and practices.
To undertake clinical education in private practices, students can offer treatments in addition to what is covered by the health insurance companies. The clinical education should be supervised by private practice physiotherapists who need to be reimbursed. Therefore, a modification of external framework conditions is necessary.
Conclusion: Private practices need financial and content-related support to engage in clinical education. Health insurance companies or the state could act as financial sponsors.
Physiotherapy Education Programs aim to qualify “physical therapists for practice as independent autonomous professionals” (World Confederation of Physical Therapy, 2011). Therefore, clinical education is an integral part of any physiotherapy education program worldwide. The World Confederation of Physiotherapy guideline for the clinical education component of physical therapist professional entry level education claims that physical therapists need to be equipped to work in a variety of different settings (World Confederation of Physical Therapy, 2011). Physiotherapists in Germany are currently educated at different educational levels, specifically at higher education institutions as well as at vocational schools. Independently from the educational level, the number of hours for clinical education does not differ and comprises 1,600 hours. Most of the clinical placements in Germany take place in acute care hospitals and rehabilitation centers (VDB, 2015, S. 8) albeit two thirds of the physical therapists work in the private sector, mainly in private practices (Destatis, 2017, S. 23-24). However, it is recognised that the demands in acute care or rehabilitation settings differ from private settings with regard to time management aspects or patient characteristics (Atkinson & McElroy, 2016, S. 116, Solomon & Miller, 2005, S. 118 & Kent et al., 2015, S. 50). This leads to the conclusion that there is a discrepancy between the current system of education and the later professional reality which most of the therapists enter (Lehmann et al., 2014). Consequently, there is a clear need for a clinical education which prepares physical therapists for work in private practice settings. Studies show that the situation in other countries, such as Canada or Australia, is comparable to the situation in Germany (Baldry Currens & Bithell, 2000; Davies et al., 2011; Dean et al., 2009; Doubt et al., 2004; Holland, 1997; Kent et al., 2015; McCallum et al., 2013; McMahon et al., 2014; Wells, 2016). Former studies on this topic focused on the perspective of the practice owners and explored the question as to why they participate only marginally in practical training (Baldry Currens & Bithell, 2000; Davies et al., 2011; Dean et al., 2009; Doubt et al., 2004; Kent et al., 2015; McCallum et al., 2013; McMahon et al. 2014).
The main barrier which deters practices from taking students, is that there is no extra renumeration for the invested time. Therefore, practical training is economically unattractive for practice owners. Additionally, the unpredictability of patients’ characteristics and diagnoses, liability concerns and the fear of decreased patient satisfaction are listed as barriers. There is also legal uncertainty regarding engaging in clinical education, with concerns that students would not be allowed to treat patients in cases where public health insurance was paying (Davies et al., 2011; Doubt et al., 2004; Kent et al., 2015; Maxwell, 1995).
On this point, legal issues regarding practical training in private practices in Germany are noteworthy. It is crucial that the existing legal regulations of the health insurances classify students as “not full therapists”. These regulations require that “pupils or students may only [work] under the constant supervision and presence of the admitted person or an appropriately qualified trainer intended for training”. Otherwise, the practice owner is not permitted to submit the therapy performed to the competent health insurance fund (Bährle, 2017, S. 15-17). The Australian Physiotherapy Association`s National Physiotherapy Service Descriptors (APA, 2012) make almost identical specifications.
Despite this, practice owners criticise that students are not sufficiently prepared for placements in the private sector, which is consistent with novices’ self-perception of readiness for working in private settings (Atkinson & McElroy, 2016; Dean et al., 2009; Kent et al., 2015). Reflecting on their own preparation, physical therapists in Germany claimed that the highest demand of working in private practice is to deal with the contradiction of time and workload, for which they are ill-prepared in educational programs (Grafe & Probst, 2012).
Otherwise, there are arguments that show the potential benefits for practice owners in engaging in clinical education, such as opportunities for recruiting new employees (Baldry Currens & Bithell, 2000; Doubt et al., 2004; Kent et al., 2015; Recker-Hughes et al., 2014; Sloggett et al., 2003). In Germany there is a lack of physiotherapists (The Federal Employment Agency Germany, 2019). Engaging in clinical education could also be used as private practice’s marketing. In that case, participating in the training of physiotherapists could have a positive impact on patients by transferring the image of a learning organisation (Recker-Hughes et al., 2014; Sloggett et al., 2003).
In summary, studies identified a lot of barriers and potential with regard to clinical education in private practice. Taking up these research findings, this study aims to analyse how cooperation between private practices and educational institutions can be achieved, from the viewpoints of both practice owners and those responsible for education. Hence, the overall goal of the study is to improve cooperation between learning locations.
The overall methodological aim was to generate new solutions by openly integrating the perspective of different stakeholders. Given this claim, a qualitative approach was chosen, using thematic analysis.
Sampling of participants was criterion-based according to Patton (1990). At first, participants should be recruited with a direct proximity to the issues of concern. Therefore, both practice owners and heads of schools were included in this study. Intersections of both groups should be identified. Inclusion criteria for all participants were a professional title of state-certified physiotherapist and at least five years’ experience, in the roles of both head teacher and practice owner. Furthermore, it was agreed that private practice owners should employ at least two physiotherapists. One person had a dual professional role as a private practice owner and a head of school. The authors assumed that the dual occupational role served a solution-oriented approach by offering views from both perspectives. Sampling occurred in the area of North Rhine-Westphalia, Germany. Three participants were recruited by e-mail invitation and one participant was invited by telephone. Most of the inquiries were successful, and the participants were highly interested in the topic, from both a practice owners and head of school viewpoint. Upon initial invitation, the subject of the interview and the inclusion criteria were outlined. Recruitment continued over a 3-week period and ceased when the participant pool included two participants for each group.
The participating practice owners were both female, 37 and 46 years old, had no experience in supervising students and had been working as practice owners for 5 and 10 years. Professional experience as a head of school varied between 22 and 37 years. One person from the two groups had an academic background. Additional demographic and institutional information are provided in tables 1 and 2.
Table 1: Overview of interview length and socio-demographic data of the heads of schools and institutional conditions of the school
|Participant||I 1||I 2|
|Interview length||105: 34 minutes||41: 14 minutes|
|Age||60 years||60 years|
|Academic degree||Sport teachers diploma||———-|
|Experience as a principal||22 years||32 years|
|Institutional training capacity||Single course||Two to three courses|
Table 2: Overview of interview length as well as sociodemographic data of practice owners and institutional data of the private physiotherapy practices
|Participant||I 3||I 4|
|Interview length||44:57 minutes||34:33 minutes|
|Age||37 years||46 years|
|Academic degree||Doctoral degree||———|
|Experience as practice owner||5 years||20 years|
|Orientation||Self-payer Private health|
|Health insurance funded (private and public)|
Problem-centered interviews were conducted to highlight the subjective view of the problem of both interviews groups (Witzel, 2000). The problem-centered interview is characterised by an inductive and deductive interplay in the process of data collection and data analysis. Thus, concrete inquiries assign deductive back covers to the elaborated state of research, which functions as a “heuristic-analytic framework” (Witzel, 2000). Throughout the process of data collection, the interview guides were modified, or new questions formulated, adapted to the findings and experiences gained during data collection.
Two semi-structured and non-standardised interview guides were constructed for each group based on Kruse (2014). Neither address the key problem directly at the beginning but approach the problem area over the course of the interview. In particular, the interview guide for the practice owners sets a biographical narrative stimulus, in which recourse is made to one’s own experiences as a professional beginner in a private practice. The aim of this consideration was to better understand the key issue on the basis of one’s own biography. In the further course of the interview, transition is made to the role of the practice owner in the present.
The interviews were conducted by the first author. The interview location was chosen by the participants and was predominantly a workplace clinic or office room. Prior to the beginning of each interview, the intention of the research was reviewed, and participants were offered the opportunity to ask questions. In addition, the author asked for informed consent to audiotape the interviews and assured the anonymisation of the data in written form (Witzel, 2000). The interviews were audiotaped and between 35 and105 minutes.
The interviews were analysed using thematic analysis, which is characterised by its independence from epistemological and theoretical positions (Braun & Clarke, 2006). Although the analysis was primarily carried out by the first author, interim results were discussed with the co-author to obtain intersubjectively discussed results. Despite its methodological proximity to grounded theory, thematic analysis excludes theory formation. This enables the data to be evaluated flexibly. Thematic analysis attempts to interpret data profoundly, rather than taking a descriptive approach. The evaluation process includes a recursive six-phase method, which includes constant movement back and forth in the analysis of the data set. Before the process begins, it is necessary to make several preliminary decisions, such as regarding the level of detail of the coding process, for example. In this study the entire data was coded. Secondly it has to be decided whether the approach to analysis should be deductive or inductive. In this study an inductive approach was chosen, meaning that no prior coding frame existed. The final question to be answered is related to the level on which themes or patterns are identified. Braun and Clark (2006) differentiate between an explicit level and an interpretative level. In this study both strategies are used: In a first step, the group-specific interviews were evaluated on a semantic level. This can be considered as groundwork for the second step, where the group-spanning evaluation was undertaken on an interpretative level. The identified intersections, in turn, provide a higher level of epistemological interest.
In the first phase “familiarising yourself with the data”, the interviews were transcribed verbatim. Reading the transcripts again and again enables the author to identify initial group-specific thinking trends on a semantic level. One item which was often quoted within the group of the practice owners was the “economic framework structure” private practices are subjected to. It could be assumed, thus far, that economic conditions seem to have a limitative impact on the provision of fieldwork placements in private practices and may develop into a main theme in due course.
The second phase “generating initial codes” involves a first manual coding of the initial data set. The transcribed interview data was coded openly line for line to produce data-driven codes. To cite a reference, for the group of the practice owners the code “fieldwork-placement first in the inpatient sector and then in the private practice” was identified, based on the following interview passage:
But there should still be a lengthy outpatient placement, especially at the end of the training. (I 3, line 280)
I think it’s important to have first had inpatient experience. (I 4, line 283)
In a second stage, sub-codes emerged, related to the main code. The following interview passage leads to the sub-code “healing process of the patient”, which supports the argument for practical training in the private practice after a fieldwork placement in the inpatient sector.
because that’s basically the same structure as for the patients. Inpatients start out weak and become stronger, and then need other things. I think it is much easier to learn when I start on a lower level, rather than a high one. (I 4, lines 285-286)
The coding process of the head of school’s data revealed a similar conception about the temporal location of the fieldwork placement in the private practice. For instance, the code “inpatient training at the beginning of the training” emerged from the data, clarified by the following interview passage:
As I have just hinted, clinical training offers many advantages at the beginning of training (I 1, lines 184-185)
Let’s just say, at the beginning of a placement, it’s certainly easier to do it in a hospital (I 2, lines 95-96).
Further sub-codes like “first professional socialisation”, “safety and routine” or “student performance as a supplementary service” substantiate the mentioned code.
In phase three, “searching for themes”, the codes were considered analytically. By sorting the group-specific codes, cross-group themes emerged from the data set. For the “code-sub-code-complex” mentioned in phase two, the overarching theme “Implications of scope and temporal location of the private practice in practical training” emerged as an interface between the two interview groups.
Figure 1 shows the result of the first three analysis steps.
| Practice owner: I think it is important to have had inpatient experience (I 4, line 283). Head of school: As I have |
just hinted, clinical training offers many advantages at the beginning of training (I 1, lines 184-185)
|Practice owner: because that’s basically the same structure as for the patients. Inpatients start out weak and|
become stronger, and then need other things. I think it is much easier to learn when I start on a lower level, rather than a high one. (I 4, lines 285-286)
Figure 1: Analysis steps 1-3
In phase four “Reviewing themes” it was checked whether topics can be deduced by their codes. The aim was to find a coherent pattern between codes and themes. In the first-place individual themes were set in relation to the whole data set. A new thematic map emerged, which shows themes, related subthemes and codes. As shown in figure 2, codes formed in phases 1-3 turn into subthemes. The following figure shows all themes with exemplary subthemes and codes. The presentation of all subthemes and codes can be found in the written results.
Figure 2: Analysis step 4
In the fifth phase of the process “Defining and naming themes”, all themes were provided with clear definitions (p. 22) which prevents an overlapping of the topics. Hence, a further specification of the topics is necessary to crystallise its content essence. The overall aim of that phase is to integrate the topic together with its associated sub-topics into the overall context of the evaluation.
The sixth step,
“Present results of the analysis”, contains a final analysis as well
as a formulated presentation of the results. The aim of this phase is to
convince the reader of the value and validity of the analysis. The analysis
should be concise, conclusive and supported by embedded examples from the data
material (p. 23).
The presentation of the results sets a pedagogical and content-related focus. Respecting the arguments for educating future therapists in private practice settings, new solutions have to be found to overcome the identified barriers. The analysis of the interview data led to some specific options that are described in the following section.
Implications of a structural and contentual learning location cooperation
It is conspicuous that the mutual ideas, in terms of content and structure, have many overlaps. School principals as well as private practice owners attribute a bridging function to the school (I 1, line 486, I 3, lines 445-446). The schools therefore put themselves into the role of initiators in the learning location cooperation and are also viewed as such by practice owners.
Supplementary to the bridging function of the school, private practice owners require an adaption performance of the school to organisational processes which are predominant in private practice (I 3, line 446, I 1, lines 506-509). One statement of a practice owner is based on the concern that the scholastic organisation of the practice phases (blocked or accompanying teaching) disturbs the routine course of practice resulting in a constant “back and forth” (I 3, line 439).
This would also lead to me having a constant change in treatments. Because when the school block starts again, the patient has to change therapists. (I 3, lines 439-441)
One head of school explains that he knows about the different organisational structures of outpatient practices. He reveals a great openness to flexibly adapting to the conditions of the cooperation partner. The impression may arise that one’s own demands are initially postponed.
There is just an awful lot of variety. And we try to really deal with this with an open hand, taking into account the different options and variations that are locally relevant. (I 1, lines 506-509)
Moreover, the aim of a head teacher is to ensure that students find themselves in a supportive pedagogical setting and that the practice creates a learning environment that facilitates practical learning. Practice owners should assume the core responsibility of “training directly on the patient” (I 1, line 495). In the following quotation a head of school describes the demands he places on outpatient practices. He anchors practice instructions as a core task:
When I say practical training takes place, then I mean that there are really contact persons who do a good job in terms of organisation, i.e. patient selection, number of patients, adequate dimensioning, right up to being there with an open ear and asking, how are things? What technical questions do you have? Every student thinks differently. (I 1, lines 242-246)
Another point is that heads of schools and private practice owners rate transparency about target agreements and learning status as being relevant for successful cooperation. By cooperation, a head of school understands that one “really has a common goal” (I 1, line 235). Therefore, explicit learning objectives for practical training must be set. The information flow contains target agreements on the therapeutic level and is to be understood as a prerequisite for patient selection. It is likely that agreements between schools and outpatient practices are important to avoid misunderstandings between the practice instructor and the student. A head of school reveals:
[…] So that the school has to define, watch out – the student can treat that, that and that. But be careful with everything else. And that would probably be the attitude, of the practice too, when it comes to professional matter. (I 2, lines 267-270)
At the content level of learning location cooperation, one practice owner has a clear idea of what the students should bring with them. Thus, it is desirable that students have at least basic knowledge acquired in theoretical and practical lessons:
You have to be in the position where the subject has been tackled before. Maybe not thoroughly, but there should be a basic knowledge there. (I 4, lines 261-263)
For one practice owner, it is important that she receives “a lot of help” (I 3, line 408) from the school, “that she […] does not leave the practice owner [alone] with it” (I 3, line 409). Thus, a structural anchored learning guidance through the schools, is desired. Regarding learning guidance provided by the school as a supplement, a head of school is apprehensive that while learning guidance from the school is desirable, it can, at the same time, be perceived as a “disruptive element” amid the organisational structures of the outpatient setting (I 1, line 502).
Heads of schools and practice owners estimate the maximum capacity of students entering in private practice to one student (I 1, line 104; I 3, line 274-275). Besides the capacity limit of one student, heads of schools, as well as private practice owners, deem fieldwork placements in private practice towards the end of practical training to be meaningful. This argument can be justified from a medical perspective, because patients first enter the inpatient setting before they seek out a private practice (I4, lines 283-287). The learning path of the students therefore follows the healing phases of the patient. In this context one practice owner points out:
[…] because that’s basically the same structure as for the patients. Inpatients start out weak and become stronger, and then need other things. I think it is much easier to learn when I start on a lower level, rather than a high one. (I 4, lines 283-287)
From a didactic point of view, the inpatient sector seems appropriate at the beginning of training. Inpatient treatment schedules are more schematic, so students can establish a routine and a first professional socialisation. There is more support in the inpatient sector, because student service is seen as a supplementary service. The contradiction between self-determination and foreign determination, which is primarily seen in private practice, seems not to be as pronounced in the inpatient sector (I 3, line 280; I 4, line 283; I 1, lines 184-185).
Another argument for this educational structure is that the treatment spectrum of private practices demands an increased level of clinical reasoning competence and professional expertise. For instance, treatment routines are interrupted, which stimulates critical thinking and confronts students with new levels of difficulty ( I 1, lines 225-228).
In practice, I must question every diagnosis made by the doctor in quotation marks. What good is lumbar spine syndrome, cervical spine syndrome, thoracic spine syndrome, I don’t even know which structure is affected. (I 2, lines 72-74)
With a preparatory function for the outpatient practice, the inpatient setting creates the breeding ground for initial therapeutic role finding. Students have the opportunity to test themselves in initial treatment processes and in the interaction with the patient (I 1, lines 138-139). For at least one practice owner it is necessary that schools prepare the students for administrative tasks (I 3, line 86). A head of school in turn hopes that the outpatient setting will give the students “insight […] into the organisational structures of a practice” (I 2, lines 274-275). For the students, this would mean that the theoretical contents concerning prescriptions and accounting would be of direct relevance in the field of practice. For the heads of schools, learning location cooperation with private practices is directly linked to the revision of the curriculum, aiming at “more teaching content that is not directed towards […] acute care” (I 2, line 236).
Implications to circumvent legal and economic barriers
The economic situation of outpatient practices often does not allow time resources to be allocated for practice guidance. In particular, it is considered a hindrance to have a state-certified physiotherapist present during treatment. For that reason, one practice owner has considered making practice rooms and patients available to schools. The advantage of this variant is that none of the employed physiotherapists have to spend any time on instruction, as this is undertaken by the teachers.
Perhaps it could also function in practice through teachers? That would also be an option. Let’s say they have an orthopedic course or teacher and need an orthopedic placement for students. I could then say, ok, on Wednesday morning, I’ll provide the rooms and patients and the teacher, with a couple of students, can work on the patients, see what has been done so far, and show or instruct techniques or exercises that are important for the patient. (I 4, lines 230-237)
In this quote, the practice owner makes a concrete suggestion for a task assignment. Thus, the teachers of the school are seen in the role of the practical instructors, while the organisational setting is performed by the practice owner. Presumably, it is possible for the practice owners to make appointments with the patient, to select patients specifically and to provide rooms. Although this option requires schools to provide teachers, it brings the advantage that the teachers can instruct “small groups” (I 1, line 170), which is comparable to the inpatient area. It can be assumed that this variant is also realistic for the heads of school, because small student groups do not require any additional human resources. The figure below (Figure 4) illustrates the proposed implementation option. If external financing is omitted, then practical instruction (PI) by the teachers of the school, who instruct small groups (several students: S) on the patient (P) proves to be practicable.
Figure 3: Physiotherapy teachers as practical instructors in private practice (Source: own illustration based on Klemme, 2012, p.60)
A further possibility is to offer patients additional treatments carried out by a student
The same goes for the patient, who is said to receive not only his six treatments, but a seventh as well. (I 4, line 188)
From a legal point of view, this option raises fewer concerns, since this form of treatment does not create a contractual obligation with the health insurance fund, but rather a private agreement with the patient (I 2, lines 46-48). The private agreement also includes informed patient consent (I 2, lines 59-60).
Of course, I can do that in practice. I say, Mrs. Müller, you have osteoarthritis. I’ll treat it, and theoretically, you can have a further two treatments per week (I 2, lines 43-46)
The head of school, who also works as a practice owner, describes how the additional treatment can be implemented. For him, it is possible to offer patients additional treatment time which is free of charge and excluded from what is usually covered by the health insurance. A practice owner further states that generous treatment time can be planned, because the student treatment can be separated from the usual time schedule (cf. I 4, line 186). In addition, it is assumed that “many patients will welcome this” (I 4, line 191). The practice owner reflects on this option by listing any initial potential hurdles. For example, it will be more difficult for small practices with only “one or two rooms” (I 4, lines 194-195) to provide rooms for student treatments than it would for larger practices. One practice owner asks herself the question “how can I do this economically? (I 4, lines 188-189). In addition, the interviewee, who has an occupational double role, notes critically: “But which private practice can afford this? (I 2, line 46). Since economic losses are presumably associated with this variant, a practice owner suggests whether it could possibly be “rewarded differently” (I 4, line 186), meaning the patient could pay for the student’s treatment, but at a lower rate than usually estimated by the health care providers. This could reduce the financial burden which arises from occupied rooms and larger treatment windows. The following figure illustrates this possibility of cooperation, which leaves open who takes over the practical guidance for the student (patient: P and student: S).
Figure 4: Student treatment as additional treatment (Source: own illustration based on Klemme, 2012, p. 60)
Implications for legal regulations and financial sponsors
To achieve a structural learning location cooperation, it would be easier for practice owners if student treatments were recognised by the health insurance company. One practice owner emphasises:
There would have to be other contracts with health insurance companies, under which student treatments could be accounted for. (I 3, lines 290-291)
Would only work from the point of view of the practice owners if the students were also allowed to treat patients independently. (I 3, lines 402-404)
Regarding self-responsible student treatments, didactical considerations are highlighted. The practice owner lists that the competences of students in the higher semesters of training, where they have already passed the “intermediate examination” (I 3, line 292) or otherwise “proved their knowledge” (I 3, lines 292-293), are considered sufficient to enable them to “treat patients alone” (I 3, lines 295-296). Compared to the examined physiotherapists the “differences in knowledge” (I 3, line 297) are no longer regarded as “so immense” (I 3, line 297). The interviewee therefore argues for self-reliant student treatments at the end of the graduate study program. Within the group of practice owners, dissonances can be identified. In this context the other practice owner argues:
This would definitely help, and if this were the case, there would certainly be more cooperation. But I see the very real danger that this would be exploited and that it would not really benefit training. Of course, this would be nice for me as a practice owner, but the question then is, how does a fieldwork placement work – is it then still a matter or training or not? (I 4, lines 298-302)
On the one hand, the interviewee points out that the relaxation of this legislation creates incentives for practice holders to participate in practical training. On the other hand, she concludes that these incentives are purely economic in nature, which could potentially be detrimental to the quality of training from a didactic point of view. At this point, a critical reflection of the professional group-specific interests becomes apparent. The framework agreements seem to have a protective function for students, since they ensure qualitative practical training. In this context, the perspective of the heads of school is important. One head of school grants the private practice owners a certain “interest in utilisation” (I 1, line 233) as long as patient care and practical training are balanced:
This should be of use to a particular department, in which capacities’ in the sense of practical training, are invested, but this must be balanced to take into account the proportions of practical training actually taking place. (I 1, lines 240-242)
To achieve a didactically and methodically valuable learning location cooperation all participants agree that external funding of student supervision is a logical consequence of the economic conditions predominant in private practices.
I think I can only afford practical instruction if I am paid for the time the student needs, for example by the health insurance company. (I 4, lines 217-219)
[…] one would have to completely change the framework conditions in the practices: i.e. free space would have to be created for practical training instructions, both in the monetary sense, i.e. that physiotherapists would really not experience any economic disadvantage as a result, i.e. funds would have to flow there. (I 1, lines 308-311)
Because, there is more to it, it’s not purely about treatment time. And by that, I mean something like the follow-up preparation and talk. Otherwise I don’t think I could manage it at all. (I 4, lines 219-221)
The last quotation from a practice owner reveals that instruction time involves more than the direct treatment time. On the contrary, it also includes the preparation of the treatment as well as the follow-up discussion after treatment. These parts of the pedagogical guidance require remuneration, since no remedial service is provided here that can be submitted to the health insurance fund. This could be seen as a basic prerequisite for being able to establish “space for practical instruction” (I 1, line 309) within the tightly calculated time structure:
If the remuneration of instruction time is played by external sources, employed physiotherapists can take over the practical guidance of the student. Figure 3 shows the triad of student, patient and practice instructor. The remuneration of the instruction time is presented as a basic factor of success in order to provide practice instructors from private practice. The pedagogically desired triad (student: S, practice instructor: PI and patient: P) can only be achieved through this option.
Figure 5: External economic resources for student supervision (Source: illustration based on Klemme, 2012, p. 60)
Both practice owners and heads of schools assess the current preparation for the private practice as deficient and derive from this the necessity of a modification of the training structure. Further studies come to this conclusion (Baldry Currens & Bithell, 2000, p. 652; Davies et al., 2011, p. 231; Dean et al., 2009, p. 45; Doubt et al., 2004, p. 49). As long as the economic efficiency of private practices increases in offering shorter treatments (Schiessel, 2013, p. 3), there is only little flexibility to integrate students in the predefined processes without incurring financial losses. A consistent synthesis of practical training and student guidance within tightly calculated treatment windows proves to be unrealistic. As the results show, instructing students is directly related to financial losses, which is listed in other studies (Baldry Currens & Bithell, 2000, p. 650; Davies et al., 2011, p. 231; Doubt et al., 2004, p. 48; Kent et al., 2015, p. 49; Maxwell, 1995, p. 585; Moore & Field, 2017, p. 46; Rodger et al., 2008, p. 60).
To anchor cooperation, it is necessary to modify external framework structures in the first place. It is then apparently possible to unite the interests of the heads of schools with those of the practice owners. The primary concern of the practice owners is to receive remuneration for the period of instruction, which is why a modification of overarching framework conditions is required first. Further conditions of success which the actors raise can be realised in the next step.
The existing health insurance policy which allows student treatments only under the condition of “permanent supervision”, is an additional impediment for practice owners to participate in clinical education. The Australian Physiotherapy Association’s National Physiotherapy Service Descriptors (APA, 2012) set almost identical standards. For the interviewed practice owners at Kent et al. (2015, p. 52), however, an impediment to taking students would only arise if students’ treatments under guidance were not remunerated. That is neither the case in Germany nor in Australia. Since the practice owners do not reward the student for his/her treatment, it can be assumed that there will be no loss due to the direct guidance situation. However, a financial loss could be expected if the student needs more time than the practice’s treatment rhythm/schedule allows. The relaxation of the existing health insurance policy is listed as a prerequisite for cooperation, but this is proving to be a point of discussion within the interview group of practice owners. On the one hand concerns are raised that the relaxation of the policy creates economic incentives for practice owners. On the other hand, the relaxation on this policy may aggravate a valuable cooperation which also considers the pedagogical and didactic interests of the students.
One practice owner suggests locating the outpatient setting towards the end of the training. She argues that, after this period. students already have increased competences and can thus be trusted to carry out treatment themselves. This may also be associated with the fact that students need less help and therefore take up less of the other employees’ time. However, Sloggett et al. (2003, p. 47) point out that there are very high expectations of the student’s competences in private practice, which can be linked to the impression that only students who already possess a high degree of social, methodological, technical and personal competence are suitable for a fieldwork placement in private practice. In support of this argument, the inpatient setting must be fundamentally distinguished from the outpatient setting, both in its professional and organisational characteristics (Atkinson & McElroy, 2016, p. 118; Kent et al., 2015, p. 50; McMahon et al., 2013, p. 15; Solomon & Miller, 2003, p. 195). Students with learning difficulties who lack critical thinking skills and creativity run the risk of not being able to cope with the complex demands of outpatient practices (Sloggett et al., 2003, p. 47). Davies et al. (2016, p. 60) underline that students need pedagogical guidance and time for reflection. Hence, the modification of this change in law must be viewed critically. If this protective space is not initially granted to the students this may lead to fear and overexertion, as described by Atkinson and McElroy (2016, p. 119) and Solomon and Miller (2005, p. 191). Existing health insurance policies in this context secure quality of care and guarantee pedagogical sanctuary. Atkinson and McElroy (2016, p. 119) argue that new entrants prefer practices that compensate the deficient educational situation and therefore provide a supportive bridging function. It can be assumed that many practices do not provide this protective space during the period of starting a career (Davies et al., 2016, p. 60) Hence, practical training should set up this protective space. To sum up, it remains questionable whether the relaxation of health insurance policies inevitably contradicts a protective space for students. This seems to be connected to how the private practice weights the student’s instruction and anchors it in the practice philosophy.
As Baldry Currens and Bithell (2000, p. 650) have already pointed out, additional remuneration for the instruction period is a prerequisite for taking on the role of a practical instructor. According to the results of this study, the health insurance funds or the federal state are seen as potential sources of finance. This raises the fundamental question of whether health insurance funds would pay for the remuneration of the educational time, since this service is not in their primary responsibility. It may appear paradoxical that the health insurance funds, which are held responsible by the interviewees for the general unfortunate economic situation of private practices, are seen as potential sources of finance. The demand for remuneration from the state can be justified, since teaching practices in medicine also receive low financial compensation from faculties (DEGAM & GEHA, 2012, p. 1).
Many consensus factors exist which are aimed at structural and content-related cooperation. In this regard, heads of schools and practice owners express concrete ideas:
The schools consider themselves to have a bridging function and are also seen by the practice owners as having this role. However, this does not mean that the heads of schools do not make any demands on the practice owners: Heads of schools expect practice owners to define responsibilities for practice instructions and cooperation with the school on a pedagogical level. For practice owners and heads of schools it is important to have transparency about the competences and objectives to be achieved. This implies clear agreements and an established communication culture. The practice owners expect the schools to prepare the students for their placement in private practice. That means that practical and theoretical learning at school is tailored to the requirements of the private practice. Further studies (Recker-Hughes et al., 2014, p. 54; Sloggett et al., 2003, p. 47) come to this conclusion. There is a consensus between school principals and practice owners that practical training in the private practice only makes sense towards the end of the training. McMahon et al. (2014, p. 17) also come to this conclusion but do not explain the reasons for the location of the private practice towards the end of the training. This justification is provided by the present study. Accordingly, this form of temporal structuring makes sense, since the outpatient setting requires an increased clinical reasoning competence compared to the inpatient setting. Probably the antinomy structure of the private practice also plays a role, which seems to be associated with higher demands in the beginning stages of the expertise. The temporal structuring also makes sense against the background of the Training and Examination Ordinance in Germany (PhysTh-APrV, 1994), which is regarded as an obstacle. It is assumable that the diversity of the patient clientele of the private practice proves to be potentially less problematic with the shortening of each fieldwork placement in the inpatient area. Practice owners and heads of schools agree that the capacity limit for student care is, at most, one student, as McMahon et al. (2014, p. 17) have previously pointed out. In comparison to the study by Kent et al. (2015, p. 49), the practice owners in this study do not explicitly wish to be included in curriculum development. Nevertheless, they consider it necessary to integrate administration-related content of the outpatient practice into the school curriculum.
Within this study, of the key issue was concerning the development of cooperation possibilities between learning locations, that do not go along with an adaptation of external framework structures.
However, the generated approaches refer to the existing influence of external framework factors, which provide only limited flexibility to the actors at the institutional level. The possibility for practices to provide rooms and patients for teachers and students is accompanied by the fact that students and teachers treat patients together in the private practice. In the triad of student-patient-practice instructors (Klemme, 2012, p. 60; Plack & Driscoll, 2017, p. 337), it is therefore not the employees of the physiotherapy practice who provide the practical guidance, but the teachers of the school. In this context, the employed physiotherapists would only have an organisational role. It could be an advantage that the temporal rhythm of the practice is not disturbed, since treatment by students and teachers can be excluded from the usual treatment rhythm. An advantage for the school organisation is that instruction in small student groups is conceivable, so that the schools would not reach their capacity limits with their personnel resources. In addition, it is noteworthy that only practice owners who have sufficient room capacity are eligible for this variant. The possibility of offering patients additional treatments provided by students goes along with a previously closed informed consent, as explained by Kent et al. (2015, p. 53). This variant is linked to the willingness of the practice owners to provide more generous treatment windows for students, and to accept economic losses, hence the results show that the additional treatment is either reimbursed by the patient not at all or only marginally. In support, Kent et al. (2015, p. 53) argue that patients have a positive attitude towards private treatments by a student if they are paid less. The advantage of this form of implementation is that the care providers are not involved. Questions that assign to a pedagogical-didactic perspective must not be disregarded. Consideration should be given to the point as to who is responsible for the student’s supervision and practice guidance. To eliminate these concerns, the possibilities resulting from the isolated consideration of the institutional level could be combined with each other. In this way, students and teachers can perform additional treatments together. Finally, it should be noted that the cooperation possibilities at the institutional level are limited to a technical-organisational cooperation, since the pedagogical tasks of the private practice are excluded. The pedagogical contribution to cooperation is either made by the school or does not take place. Although these possibilities are less consistent with the basic concept of cooperation, including a “technical-organisational and pedagogical interaction” (Müller & Bader, 2004, p. 91) of both institutions, the combination of both variants could initially establish itself as a transitional solution as long as modifications of external framework structures are pending.
The current gap between practical training and professional reality can only be bridged by an increased involvement of private practices in practical training. Both practice owners and heads of schools have shown a high degree of willingness to develop solutions aimed at institutionalising practical training in the private practice.
In this article, we have outlined possibilities of cooperation between private practice and schools which address the institutional level. However, these possibilities appeal to the motivation, goodwill and willingness of the practice owners to coordinate organisational processes with practical training. To validate these possibilities, it is necessary to develop research projects that evaluate the feasibility and the use of different options.
An increased participation of private practices in practical training must include a modification of external framework structures, aimed at a remuneration of the instruction time. Further studies should include the perspectives of health insurance companies and politicians.
Private practice owners can provide rooms and patients if practical instruction is not remunerated. The practical instruction itself can be carried out by teachers from physiotherapy schools. To circumvent health insurance policies, it is possible to offer additional treatments conducted by a student. In this case, students can offer longer treatment sessions to increase the learning potential. Furthermore, the supervision of students during practical training can have the benefit of an early recruitment of employees for practice owners.
Interview guide: practice owner
- First of all, tell me how it came about that you started working in a private physiotherapy practice?
- Linking up with the previous question: If you remember entering into a private practice, will you tell me how you experienced it?
- Perhaps you can also remember to what extent you were prepared for working in a private physiotherapy practice during your training?
- What do you think characterises employment in a private physiotherapy practice?
- Now you are in the role of the practice owner. What goes through your mind when you receive applications from newcomers?
- What is your impression as to how quickly newcomers find their feet in the private physiotherapy practice?
- On the basis of your experience both as a newcomer to the profession and as a practice owner, how do you assess the overall preparation of training for work in a private physiotherapy practice?
- The practical training of physiotherapists in Germany primarily takes place in hospitals. To what extent do you think does it make sense for students to gain experience in a private physiotherapy practice during their practical training?
- Let us assume that you would have the opportunity to guide in your practice. What advantages could this have for you as the practice owner?
- There is very little cooperation between private physiotherapy practices and physiotherapy schools in Germany or abroad. What do you think are the reasons for this limited cooperation
- What would help you to guide students in your private physiotherapy practice?
- From my side, there are no more questions. Is there anything else from your side that hasn’t come up now, that you would like to share or that is going through your mind now?
Interview guide: head of school
- First of all, I would like to know something about your school and the training you offer here.
- Next, I would like to hear from you how you organise the practical training at your school? Have you already entered into learning location cooperation with private physiotherapy practices?
- Have you already entered into learning location cooperation with private physiotherapy practices?
- In your opinion, what is the difference between practical training in private physiotherapy practice and inpatient training for students? It would be nice if you could name the main differences.
- The next thing I would like to know is where you see the advantages of inpatient training?
- From your point of view: Who would benefit from integrating private practices into practical training and why?
- One can summarise in general: Private practices are only marginally involved in the practical training. In your opinion, what are the reasons for the lack of cooperation?
- To what extent would the involvement of the private physiotherapy practice lead to a change in the school’s internal curriculum?
- I am interested to know which options exist for involving private practices in the practical training?
- If you had creative freedom: What would be the optimum practical training in 2025?
- There are no further questions from my side. Is there anything else from your side that has not been discussed now, that you would like to share or that is going through your mind right now?
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