Exploring barriers, advantages and potentials in realising clinical education in private physiotherapy practice settings in Germany

Article accepted

This article has been accepted for publication. Peer reviews and author responses are available at the end of the article.


Background: Traditionally, the clinical education of physiotherapy students in Germany takes place in inpatient settings. Against the background that the majority of graduated physiotherapists work in private 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 advantages, barriers and options of collaboration between physiotherapy educational institutions and private practices. Methods: A qualitative interview study was conducted, in which two practice owners of a physiotherapy practice and two programme directors were interviewed using a problem-centred interview approach. All participants were contacted via email or telephone. Textual data was analysed using thematic analysis, to inductively discover and describe relevant themes. Results: The economic conditions of private practices in Germany, legal requirements and training regulations are identified as the main barriers preventing forms of collaboration. One of the advantages of offering students practical placements is their probable future employment. Successful collaboration may depend on remunerating clinical instruction time, relaxing legal requirements or increasing the participation of schools in practical training. Conclusion: Private practice needs financial and content-related support to engage in clinical education. Health insurance companies or the government could act as financial sponsors.


Thank you for the invitation to review. Given that many of our graduates end up in the private sector, it seems logical that physiotherapy training programs should include this setting within undergraduate curricula. What concerns me though is the obvious perception that it is acceptable to allow students to learn and ‘practice’ on patients within the public health care domain, but that it is not alright to do so in the private sector. Bar the possible financial constraints on the private practices, the multiple benefits for all stakeholders are seldom further investigated.

Given my statement above, it was disappointing to find that this study has not really added to the current body of knowledge/evidence concerning the challenges of having undergraduate PT students train in private practice. The study suggests that it aimed to find ‘solutions’ yet still excessively focuses on existing barriers. The study concluded that change is necessary – but then does not elaborate on this.

A further concern is the very small sample size given that Germany has 36 or more training institutions for physiotherapy. How were these participants identified and recruited? Similarly only two practitioners working in private were invited to participate, one of whom works in both sectors – did this not lead to bias? It is unlikely that their responses are similar to the rest of the population and this study therefore lacks generalisability.

Do you have ethical clearance and or was the proposal externally reviewed?

In general the manuscript is too long, and although the transparency concerning the qualitative methods you have used, are unnecessary and has lead to a lot of repetition. To the reader this then becomes boring.

My recommendations for improving this manuscript are thus:

  • consider changing the title – you have not developed a framework nor any model/s for cooperation to facilitate the inclusion of the private sector into the undergraduate (UG) clinical training program and as my co-reviewer pointed out, the local setting and challenges vary significantly between countries and perhaps elaborating on the German context will add value.
  • ‘Tighten up’ the methodology as well as the results sections and try to keep your focus on the information/data that can assist in ‘bridging the gap’ or rather fostering cooperation between the schools and the private sector
  • Why did you select heads of schools and not the undergraduate program coordinator or clinical training coordinators? And why share their qualifications, funding model etc. – this seems irrelevant to the topic and makes them identifiable.
  • What measures did you put in place to ensure trustworthiness?
  • ‘contentual’ learning – do you not mean contextual learning?
  • Discussion – begin with what the major findings were and then proceed to discussing each one. Again – keep focused on what is needed to foster better cooperation and propose how this could be done in line with recommendations from the literature e.g. remuneration seems a key consideration – what about proposing other models for remuneration? Continuous professional development, a university accredited practice etc.
  • What are this study’s limitations? Discuss the implications of the purposive  sampling and small sample size? Any suggestions for further research?
  • Practical implications – this section I would rewrite to summarise clearly the issues and some of the ‘solutions’ to the issues


In general, the manuscript focus on an interesting topic within physiotherapy education, that is how we can implement clinical placement into the education, which is relevant for the later working-life for students. This may be dependent of new models of cooperation between universities and clinical settings. I think this is a general challenge across countries. When it comes to financing of primary care physiotherapy, the authors should be aware that there may be huge differences between countries; for example in the Scandinavian countries the public financing of primary care physiotherapy, is probably much higher than in Germany(?). Thus, I think it would improve the manuscript to put most emphasize on the principal problems, which again I think are the same, independent of financing. Did the informants from the private clinics also see benefits of cooperating? For example, rising standards as a consequence of having students who were recently taught in evidence-based physiotherapy? This is obviously a two-way relationship where also clinics have to change.

Several places in the manuscript, statements from informants are cited. For example  “….as private practice owners attribute a bridging function to the school (I 1, line 486, I 3, lines 445-446)”. Thes reference to lines should be removed. In addition, I would recommend that such citations are kept to a minimum, and are only used in cases were a statement inform the themes analysed. .

The manuscript is too long and will profit on being shortened, I think this would be easier with a new, and tighter structure. Lastly, the ethical issues commented on, needs to be addressed.

Thank you for giving me the opportunity to review the manuscript – this is a really important and interesting topic!


Specific comments


The abstract generally reads well and provides an overview of the study. However, in the methods section it should be more clearly stated whether the interviews were individual and how the informants were recruited. The conclusion only to a little extent answer the aim of the study, which was to identify new models of cooperation.



First paragraph is generally well written and explains the discrepancy between where physiotherapists work and where they have their clinical placements. However, the authors do not explain the reason for why physiotherapists currently, to a lesser extent work in acute hospitals. I find the claim that “there is a clear need for a clinical education which prepares physical therapists for work in private practice settings”, a bit difficult and probably dependent on country and health care system. Instead, one could argue that the is a need for education preparing physiotherapists for primary care settings – independent of whether it is public or private.

Second paragraph starts with “the main barrier….”, I will suggest to start with one or two sentences explaining why private practice clinics in Germany could offer a valuable contribution to the education. Thereafter, you could write about the potential benefits with respect to increased cooperation, such as recruitment of future staff, improved standards among staff? etc. Finally would could address some of the barriers, leading up to the aim.

“The overall goal of the study is to improve cooperation between learning locations”. Research studies seldom have goals but rather aims or objectives. This “goal” should be rephrased. I would suggest something pointing to the exploratory nature of the study, such as to identify possibilities, challenges and barriers for….. If you agree to this, the results section should be structured accordingly. This would greatly improve readability!

A more general question to the authors I whether some additional literature on similar challenges in bridging education and practice within health education, could have been added. I should admit, though, that I am not deeply into the literature within this field.



There is no such thing as “methodological aim”, this is only confusing.

The recruitment process is in many aspects well described, however, were the informants randomly chosen based on the criteria, or was it rather a strategic sample?

Sentence that reads: “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” Due to ethical reasons, I would strongly suggest that you do not provide this combination of details, which easily make it possible to identify the informants. In addition, you have already described, in which region of Germany the research takes place. Tables 1 and 2 provide too much detail, instead present as text in less detail.

“The interviews were conducted by the first author”. Here you should add some information of the background of the first author, i.e. past experiences with interviewing and doing similar analyses.

“The interviews were audiotaped and between 35 and105 minutes”. Were the interviews also transcribed by the first author? Add a sentence about this.

The analyses is really comprehensive and explained in great detail. I wonder whether some of the information presented, such as the bits with citations, are rather part of the result section. Please consider this.

There is no information about ethical considerations in the manuscript, except from the informed consent. Did the study receive any institutional approvals? Or any data protection approval (GDPR)? If not, it should be explicitly stated why not. This type of data cannot and should not be considered anonymous.



This section is really comprehensive and should be restructured and also shortened (see comment earlier about the aim). This again, has major consequences for how the discussion is structured.



What were the 3-5 most important findings? Discuss them one by one, accordingly. The discussion section should also address important methodological issues, such as limitations with respect to analyses etc. The number of informants Is low, what could have been the results with a higher number of informants, or if the informants were recruited in other regions? Could it have been an alternative to perform focus-group interviews in this case. Why, or why not?



“The current gap between practical training and professional reality can only be bridged by an increased involvement of private practices in practical training”. This is a claim that is beyond the “goal” and which may not be justified by the empirical findings. The conclusion points back to the aim, thus it needs to be rephrased accordingly.


Practical implications

I would suggest to remove this section, because I do not think there are any. The scope of this type of study is to increase knowledge about a problem and thus to guide decision-making and further research.

Conflict of interest statement

The authors report no conflict of interest.