Motivations, Main Challenges and Needs of Physiotherapists for Setting up a Private Physiotherapy Practice in Estonia: a Mixed Methods Study

Introduction

Physiotherapy is an essential area of healthcare that promotes maximum functional capacity across the lifespan when mobility and function are compromised by aging, injury, disease, and environmental factors.¹ Physiotherapists work in various settings, including hospitals, rehabilitation centers, primary health care organizations, outpatient clinics, schools, private practice, etc.² Different working environments can have different advantages for a physiotherapist. For example, in an outpatient hospital, a physiotherapist has a secure job and salary and direct contact with doctors and other health professionals, but also has to deal with a larger number of patients. Working in the private sector or as an entrepreneur can give physiotherapists greater autonomy and even higher salaries.³ Although private physiotherapy has been a reality on all continents,⁴ the need, scale and form of private physiotherapy is likely to vary from country to country.⁵

While almost 80% of physiotherapists in Finland worked in private practice in 2015,⁶ there are no exact figures for Estonia. An increasing number of people are working in parallel in both the public and private sectors, but there is no precise overview of how many of them are currently in full-time employment and who are simply working in private practice as specialists. However, in recent years there has been an increasing interest in setting up private physiotherapy practices. This has been facilitated by a law amendment that entered into force in October 2023, which put physiotherapists (partly) on an equal footing with other health care professionals⁷ and gave them quick access to a patient’s medical history and the opportunity to participate in the patient’s treatment process as an independent specialist.⁸ At the beginning of 2023, according to our data, 77 physiotherapists were self-employed in Estonia, while it should be noted that according to Eurostat statistics⁹ there were only 572 professionally employed physiotherapists in Estonia in 2021 (total Estonian population as of 1.01.2024:1349687 inhabitants).¹⁰ However, setting up a private practice raises several questions, in particular regarding preparation, but also the main motivators and challenges in starting a business.

Although studies have been carried out to explore novice physiotherapist perspectives on preparedness for work in private practice,^11,12 the science literature on setting up a private practice in physiotherapy is scarce. Still, Perreault et al¹³ estimate that the main challenges for physiotherapists in setting up a private practice are resource management and marketing. Limited financial resources can strain a start-up, for example, buying equipment and premises or outsourcing services. Finding clients can be an additional challenge when entering the labor market. This means that in addition to clinical and business management skills, physiotherapists in private practice need to improve their marketing skills. Examples from Finland⁶ and Australia¹⁴ from around a decade ago suggest that higher education institutions training physiotherapists do not invest enough in preparing students for private practice. It can be speculated that the situation has changed in these countries. At the same time, however, the educational curricula offered by higher education institutions are understandably more focused on theoretical knowledge and clinical skills in physiotherapy, particularly in the clinical setting, to the detriment of entrepreneurship education and practical business management training. This education gap may leave future physiotherapists unprepared to face the challenges of business (such as business planning, developing marketing strategies, and managing client relationships).

Entrepreneurship education has an important role to play in today’s higher education and will have a significant long-term impact in shaping a more competitive and innovative future.¹⁵ However, more substantive input is needed to provide better quality teaching in the context of curriculum and training program development. However, when organizing it, the specific need and cost-effectiveness of the corresponding training should be considered. This study therefore aimed to determine what motivated physiotherapists in private practice in Estonia to set up a business, the main challenges they faced in their endeavors, and the support they needed from higher education institutions and the Estonian Association of Physiotherapists.

Materials and Methods

The study was approved by the Research Ethics Committee of the University of Tartu (protocol no: 384/T-1, 20.11.2023). The survey was conducted in accordance with the guidelines of the Declaration of Helsinki; all respondents had to tick a box before completing the electronic questionnaire to confirm that they understood the purpose of the survey and consented to the processing of their data. The IP address of the respondents’ computer or other device used to answer the questionnaire was not identified. The collected data is stored and processed in a secure system of the Tartu Applied Health Sciences University. In all published materials, the data will be presented in a manner that respects the participants’ privacy and ensures their confidentiality.

In early January 2024, an invitation to the survey, along with a link to the questionnaire (www.limesurvey.com, LimeSurvey GmbH), was sent to the head of the Estonian Physiotherapists Association’s Private Practitioners Interest Group. He shared it with all 77 members of the group. This interest group maintains a contact list of all physiotherapists who have established private practices in Estonia. The response period was one month. The target was set at a response rate of at least 20–25%, which is considered necessary to interpret the results for a smaller sample (n<500).¹⁶ To increase the response rate and to remind the purpose of the survey, a follow-up invitation to complete the questionnaire was sent two weeks after the initial invitation.

The development and piloting of the questionnaire (included as supplementary material) aimed at exploring the motivations, challenges, and needs of physiotherapists for establishing a private practice in Estonia was designed with input from relevant literature¹⁷ and aligned with the study’s objectives. The questionnaire primarily consisted of multiple-choice questions and Likert-scale items (1 – strongly disagree to 5 – strongly agree). To capture a comprehensive view of the challenges involved in setting up a private practice, participants were also invited to describe their biggest challenge in a free-response format. In the case of these open-ended questions, an attempt was made to quantify certain elements. To do this, the frequency of specific keywords was counted in order to gain an understanding of how often certain topics were mentioned.

The legal terms used in the questionnaires were provided by a lecturer in entrepreneurship (Priit Pajuste), who is also one of the authors of the article. The questionnaire was piloted on two physiotherapists set up by a private practice. Two of the questions were reworded according to the feedback received, but the meaning of the questions did not change. Thus, these two pilot questions were included in the questionnaire for the final data analysis. As a result of the pilot, the questionnaire took about 15 minutes to complete.

The questionnaire consisted of three thematic blocks:

1. Motivations for starting a business: This block contained 18 statements related to motivational factors, which respondents rated on a 5-point Likert scale, with an option for additional comments.
2. Challenges and Needs: This block included 14 statements rated on a 5-point Likert scale, supplemented by a free-response question asking participants to describe their biggest challenge in setting up a private practice. Additionally, multiple-choice questions assessed whether respondents felt adequately prepared by their university education to start a business and whether they sought assistance from the physiotherapists’ association.
3. Business-related Factors: The third block focused on aspects related to the business itself, including prior experience with setting up a business, whether external services were purchased during the setup, and the need for financial support. This section included a mix of multiple-choice questions and Likert-scale ratings.

The software program Microsoft Excel for Microsoft 365 MSO (Version 2409) was used for descriptive statistics and illustrations. Results are presented as means with standard deviations (±SD), or proportions with percentages. To measure motivations and challenges for starting a business Likert scale (5-point) were used.

Results

A total of 16 physiotherapists (♀=14, ♂=2; with age 37.1 ±5.46 years) who had established a private practice participated in the study, representing one-fifth (21%) of the physiotherapists who had established a private practice in Estonia at that time of conducting the study. One respondent obtained higher professional education abroad, most of the respondents (n=15) in Estonia between 2001 and 2023, nine of them with a master’s degree. Private practices were set up between 2010 and 2023. 11 respondents (68.75%) rent premises; three (18.75%) own premises; one (6.25%) owns and rents premises; one (6.25%) only makes home visits and therefore does not need premises.

Ten (62.5%) estimated that they had no understanding of the business process before setting up a private practice, four (25%) had some understanding and two (12.5%) had at least a good understanding. Six (37.5%) had previous exposure to entrepreneurship before setting up a physiotherapy private practice. Five of them felt that their previous experience contributed significantly to creating a private physiotherapy practice.

Motives for the Creation of Private Practices

For all respondents, the most common motivation for starting a private practice was autonomy, including flexible working hours. The remaining motivators reported by physiotherapists are shown in Figure 1. Neither family traditions nor personal role models were motivators in setting up a business; similarly, physiotherapists do not seem to prefer team building or managing others.

Figure 1 Motives for the creation of a private practice for Estonian physiotherapists – five-point Likert scale.

Challenges Encountered in Setting up a Private Practice

None of the respondents agreed that higher education in physiotherapy adequately prepared them to start a business, and all agreed that they need to learn more about entrepreneurship on their own (Figure 2). More than half of the respondents (63%) cited financial difficulties in finding start-up capital, and half (50%) cited financial difficulties in further professional development of the business. While a third (33%) acknowledged difficulties in finding customers and three quarters found it challenging to differentiate themselves from the competition, almost 80% (n=13) agreed that they found it easy to retain the customer base they had gained.

Figure 2 Challenges in setting up a private practice for Estonian physiotherapists.

The most frequent responses of the subjects to the open question “Describe your biggest challenge in setting up a private practice!” were related to finding clients (n=6). This was followed by entrepreneurial knowledge and education/training, which were mentioned three times. Other challenges cited were:

• Start-up costs and financial resources (n=2).
• Business management and workload (n=1).
• Setting up a private practice without difficulty (n=1).
• Personal development and self-esteem (n=1).
• Finding and setting up a workspace (n=1).
• Developing collaboration (n=1).

All respondents felt that higher education in physiotherapy did not adequately prepare them for entrepreneurship. In addition to the predefined answers, marketing skills were mentioned three times, and project writing skills were mentioned once. The most felt lacking were:

• Legal knowledge of setting up a business (n=15).
• Economic knowledge of setting up a business (n=15).
• Knowledge of setting up a business (n=14).
• Knowledge of keeping a business alive (n=14).
• Knowledge of support services and grants available (n=14).

Seven (43.75%) respondents needed help finding customers. They estimated that the following factors may have had an impact on finding clients: lack of money to market themselves (n=6); lack of skills to market themselves (n=4); lack of time to market themselves (n=3); lack of client confidence (n=2); inadequate website (n=1); poor private practice location (n=1); too expensive fees (n=1); inappropriate office hours for clients (n=1).

Support Needed to Set up a Private Practice

11 respondents (68.75%) did not seek support from the Association of Physiotherapists to set up a private practice. Those who did ask for help from the Association (n=5) received help in the following areas: finding premises (n=3), legal aspects (n=3), data protection (n=1), drafting contracts (n=1), health and safety (n=1), finding clients (n=1) and marketing (n=1). Four respondents (25%) needed financial support to set up a private practice. They were asked to specify the sources of support. Different forms of possible support were mentioned: the “The Talented Come Home” program, the Unemployment Fund, spouses and student loans.

In addition to support for setting up a private practice, physiotherapists also buy in/bought out the following services: bookkeeping for 10 respondents (62.5%); setting up a website for 6 respondents (37.5%); IT services for 6 respondents (37.5%) and cleaning of premises for 3 respondents (18.75%).

Discussion

Previously have been shown,^18,19 that desire for self-development and the opportunity to challenge oneself are important motivators for setting up a private practice, and this is also suggested by the results of our survey among physiotherapists who have set up a private practice in Estonia. All of our respondents confirmed the need to ensure autonomy, which is in line with the results of studies on other professions.^18–20 Autonomy in the work environment refers to the extent to which workers organize their work schedules, determine their own work organization, and use their own initiative or decision-making power to complete their work.²¹ Greater work autonomy can increase employee satisfaction.²² Indeed, Latzke et al²³ have described that overall job satisfaction and aspects of autonomy are higher for self-employed physiotherapists compared to physiotherapists working in the public sector.

Although studies show that higher wages are an important motivator for starting a business,^24,25 the results of this paper do not reflect this so clearly. In Estonia, the average gross monthly salary of a physiotherapist in the second quarter of 2024 was €2168 (an increase of 11.9% compared to the previous year), which is essentially equal to the average gross salary in Estonia (€2007).²⁶ Unfortunately, no data are comparing the salaries of physiotherapists working in the private and public sectors in Estonia, but based on data from Rivers et al,²⁷ it can be assumed that private sector salaries are still higher. However, physiotherapists who have set up a private practice admit that finding start-up capital is a challenge and that there are financial difficulties in further professional development of the business. However, they are reluctant to create a team and work together, which would not only help to share resources but also to improve the quality of the service by working together and developing teamwork. The ability and willingness to collaborate interprofessionally (including interprofessional collaborative practices) would also help to address the latter challenges, including in terms of ensuring quality services.²⁸

Physiotherapists in private practice in Estonia admit that they had to learn on their own to open and maintain a private practice, and that finding new clients was not easy. According to Finnish physiotherapy students, higher education does not adequately prepare them for marketing themselves⁶ and it can be assumed that the situation is similar in Estonia. For example, at the Tartu Applied Health Sciences University, the Entrepreneurship course (3 ECTS) focuses on business plan development using iPlanner business plan software,²⁹ while marketing is covered in one seminar (2 academic hours). As the physiotherapy curriculum in Estonia is only 3 years long (180 ECTS) and a large part of the curriculum is still clinical, there is no justification for increasing the volume of the entrepreneurship course. It is also important to mention that since physiotherapy education in Estonia is mostly publicly funded (except part-time), the authors believe that entrepreneurship education should be offered primarily on an elective basis, as part of continuing education provided by professional associations and at a stage in the professional development of physiotherapists when they are able to fully understand the ethical dimensions of their professional responsibilities.

However, the results of the survey give an indication of the direction in which the content of the Entrepreneurship course should be developed (eg marketing and project writing skills). As of the new academic year (2024–2025), a separate 2 ECTS credit elective will be offered to physiotherapy students, covering business management, economics and marketing in more depth. The professional association (Estonian Physiotherapists Association) should certainly continue to pay attention to supporting entrepreneurship alongside the core curriculum in undergraduate studies. In addition to representing the interests of their members and influencing health policy,³⁰ professional associations have an essential role in providing professional preparation and continuing education.³¹

The private sector could reduce waiting lists for physiotherapy services, as has been shown in Ireland³² and is hoped for in Estonia. At the same time, however, the physiotherapist is also an important member of the primary care team, and networking and communication between team members is essential to ensure quality of care.³³ Unfortunately, this study did not address the extent to which physiotherapists who have established a private practice perceive that communication with, for example, the treating physician is ensured, and the extent to which physiotherapists perceive that access to patients’ medical records is sufficient for quality service delivery.

Another limitation of the survey is the methodology (electronic questionnaire) and the small number of respondents, which makes generalisations impossible. The use of structured interviews would certainly have provided a more meaningful picture of the situation. At the same time, it should be considered that in 2021, there were only 572 physiotherapists working professionally in Estonia, which also means that in terms of European statistics, there are very few physiotherapists per 100,000 inhabitants.⁹ The proportion of male respondents is justified because Estonia, Hungary, and Slovenia have a high proportion of women physiotherapists.³⁴ This manuscript is sometimes based on decades-old sources, but unfortunately, there is no more recent literature specifically on the establishment of private physiotherapy practices. As early as 2006, Nabi et al³⁵ pointed out that not enough attention was being paid to this issue. However, the topic is essential for developing health curricula, especially given the shortage of health professionals and the availability of health services. Thus, we fully agree with Salminen et al³⁶ that entrepreneurship skills are necessary for healthcare due to changes in working life. At the same time, a national decision on the need for private physiotherapy practices would be needed to organise, where necessary, the distribution of subsidies for the creation of centers and the acquisition of the necessary skills in professional associations, for example in cooperation with business schools.

Conclusion

The primary motivation for physiotherapists to set up a private practice is autonomy (including flexible working hours), but not to set up centers in collaboration with colleagues or to manage others. In the context of changes in professional legislation and the emergence of private practice, it is important to ensure needs-based entrepreneurship training in higher education, as well as continuing education in cooperation with professional associations.