Exploring the Concept of Leadership from the Perspective of Physical Therapists in the United States

Abstract

Purpose: The purpose of this study was to examine the perceptions of physical therapists practising in the United States of the importance of leadership characteristics and of demographic traits and other factors that might be associated with perceptions of leadership in three contexts: workplace, health care system, and society. Method: An online questionnaire was distributed through snowball sampling to physical therapists practising in the United States over an 8-week period between October and November 2019. A total of 15 leadership characteristics were rated on a 5-point scale of importance. Results: A total of 278 physical therapists responded to the questionnaire. They rated communication and professionalism as the top two leadership characteristics across all settings. Self-awareness and business acumen were not perceived as important for leadership. No relationship was found between gender and self-declaration as a leader or between a participant’s practice setting and their rating of the importance of leadership characteristics. Conclusions: Our results further the discussion of leadership in the physical therapy profession. They highlight a comprehensive acceptance of leadership characteristics as important regardless of context. Further work will be necessary to transition this declaration of the importance of leadership skills to identifying the essential leadership skills for physical therapist education and clinical practice.

Leadership across and within all levels of health care delivery is essential to improve quality of care, expand patient safety, and control costs.^1–3 Research has suggested that the transformational change needed in health care must substantially come from the leadership of all point-of-care clinicians in the workplace, regardless of whether they take part in formal management roles.⁴ Historically, business acumen and knowledge have been recognized as being necessary for those in formal or positional leadership roles, regardless of health profession.⁵ Those serving in these positions have acted as intermediaries among point-of-care clinicians.^3,5

More recently, health care organizations have recognized the need for both formal leadership training and informal leadership roles distributed throughout the system to promote and advance innovative health care practices.^5,6 Critical to physical therapists’ roles as agents of change who transform society by optimizing movement is the need to demonstrate leadership skills.⁷ Demonstrating such skills will enable therapists to remain professionally resilient, make informed decisions to bridge clinical care and business pragmatics, and adapt to conditions for individual care while addressing the greater needs of populations and society.⁸ As noted by Desveaux and colleagues, “Research on leadership has identified a set of characteristics required to deal with complex systems, rapid change, and expansion of knowledge in healthcare, information technology, and business.”^{9(p. 368)}

Internationally, three studies have been published regarding physical therapists’ perceptions of the importance of leadership characteristics across three contexts: workplace, health care system, and society.^9–11 The participants in these studies were primarily women, identified themselves as leaders, worked in an outpatient or hospital setting, and had earned either a baccalaureate or a master’s degree in physiotherapy. Approximately half supervised students.^9–11

In 2012, Desveaux and colleagues explored physical therapists’ perceptions of leadership in Canada.⁹ In this study, physical therapists perceived the leadership characteristics of communication, professionalism, and credibility to be the most important among 15 leadership characteristics studied across contexts. Those working in private practice perceived that business acumen was also an important leadership characteristic. Approximately 80.0% of the participants self-declared as leaders and reported being of male gender, and they primarily worked in private practice or an academic institution and supervised students.

In 2014, Desveaux and Verrier explored the perceived importance of leadership characteristics at the workplace level versus the societal level and reported that although the three most important characteristics remained the same, significantly fewer participants chose the “extremely important” ranking at the societal level than at the workplace level.¹⁰

McGowan and colleagues replicated this study in Ireland in 2016 with some adaptations to the questionnaire to fit the Irish medical system.^8,11 Communication and professionalism were rated as the two highest characteristics across the three contexts of workplace, health care system, and society. The highest degree attained was associated with those who declared themselves to be leaders.

Outside the realm of physical therapy, multiple health care professions, such as medicine and nursing, related effective leadership with emotional intelligence (EI), vision, and business acumen.¹² Nicol and colleagues determined that high levels of EI and relationship skills were two of the most important and universally selected attributes health care leaders need to be successful in leadership.¹³ This is in direct contrast to physical therapy studies, which identified effective leadership with communication, professionalism, and credibility.^9–11

Demographic and other factors have played a significant role in physical therapists’ perceptions of leadership characteristics. Gender, as a social identity, has been explored in physical therapy. To illustrate, Sebelski published the first study on U.S. physical therapists’ perceptions of leader self-efficacy that included gender.¹⁴ The participants reported moderately high confidence in all areas of the Leadership Efficacy Questionnaire regardless of gender, age, percentage of time spent in various contexts, or attainment of specialization.

In 2018, a Delphi panel of American experts from the academic to the clinical environments rated the level of importance of leadership knowledge, skills, and abilities (KSAs) in the domain of leadership.¹⁵ A total of 76 competencies of leadership were rated for their level of importance for new graduate physical therapists (≤1 y post-licensure) compared with physical therapists who were more than 1 year post-licensure. The Delphi panel was not asked to consider context, as had previous studies.^8,9,14 The findings were consistent with physical therapists’ and other health care professionals’ opinion that communication, professionalism, EI, self-confidence, team orientation, and trustworthiness were important to physical therapist practice in the United States.

On the basis of the synthesis of findings from national and international physical therapists and other health care professionals, we chose to examine leadership characteristics, practice settings, demographic traits, and other factors that might be associated with physical therapists’ perceptions of leadership characteristics in the United States. The vision of the American Physical Therapy Association (APTA) to “transform society by optimizing movement to improve the human experience” suggests that physical therapists’ roles in the contexts of workplace, health care system, and society require an understanding of leadership requirements across these settings.⁷

Thus, the purpose of this study was to explore the perspectives of physical therapists practising in the United States on the importance of leadership characteristics and of demographic traits and other factors associated with their perceptions of leadership across three contexts: workplace, health care system, and society.

Methods

Questionnaire design

The research study was approved by the Institutional Review Board (IRB; Protocol 29456) at Saint Louis University in St. Louis, Missouri. With permission from Desveaux and colleagues,⁹ we used the three-section questionnaire from their 2012 study as the foundation for this study. Section 1 queried the participants on 15 leadership characteristics across three contexts: workplace, health care system, and society. Sections 2 and 3 addressed leadership training, collected personal and workplace demographics, and queried the participants’ formal and informal leadership development. An open comment box was available to the respondents. The wording of the questions in Sections 2 and 3 was such that the respondents did not have to identify themselves.

Minor modifications to the questionnaire had to be made to improve its relevance to the United States in the areas of workplace and health care system. For example, we added self-management to self-regulation and substituted broader environment for global environment. We did not change the term social dominance to social influence so that we could later compare the perceived importance of characteristics in the United States with those in Canada and Ireland.

The participants were asked to rate the importance of each leadership characteristic across the three contexts, using a 5-point ordinal Likert-type scale anchored by 1 (not at all important) and 5 (extremely important). To reduce the risk of differences in interpretation, working definitions of the terms used in the questionnaire were provided and remained visible to participants as they worked through the questionnaire (see Box 1).

Box 1 . Operational Definitions.

• A leader is an individual who influences the actions of another individual or group toward accomplishing shared goals and sets the pace and direction of change while facilitating innovative practice.

• Workplace setting refers to the current practice environment.

• A health care system is a combination of resources, organization, financing, and management that culminates in the delivery of health services to the population.

• Society refers to the global environment in which the community functions.

Participant recruitment

Because there is no single professional directory of email addresses for all physical therapists in the United States, we used a non-probability-based sample technique, snowball sampling, to attain a wide sampling of physical therapists. Snowball sampling is a two-step process that is typically used with hard-to-reach populations.¹⁶ Physical therapists with accessible email addresses were identified through our personal contacts, through publicly available email addresses, and from lists in the sections or academies of APTA. One state’s email list of licensees was obtained as well and used to target participants.

Each invitation email contained the URL link to the questionnaire and specified that each contact should forward the invitation email to possible participants; this resulted in a type of chain referral process.¹⁶ Completing the questionnaire denoted a participant’s informed consent. Qualtrics XM, a web-based programme (Qualtrics, Provo, UT), allowed us to develop and distribute anonymous questionnaire instruments.

Data collection

Data were collected during an 8-week period in October–November 2019. The participants’ responses were entered into Qualtrics XM. A reminder email was sent within 10–14 days of the initial invitation email. Raw data were password protected and available to us only with IRB approval.

Data analysis

Data were exported from Qualtrics XM and imported into the IBM SPSS Statistics, Version 26.0 (IBM Corp., Armonk, NY). Frequency distributions and percentages were obtained for each leadership characteristic across the three contexts of workplace, health care system, and society.

To answer the research questions about what impact, if any, practice setting had on the level of importance of each leadership characteristic in each context, the participants were grouped for each leadership characteristic by reported practice setting: acute care or rehabilitation hospital, outpatient clinic or private practice, academic institution, or other facility type. For statistical analysis, all facilities were pooled as other when examining one specific practice setting. For example, when examining the impact of academic institution, the practice settings of acute care or rehabilitation hospital, outpatient clinic or private practice, and other were all grouped as other. For differences in level of importance of leadership characteristics, the rating categories of not at all important, not very important, and neutral were grouped as not important, and the categories of very important and extremely important were grouped as important. The significance level was set at p < 0.05.

We combined χ² analysis with post hoc analysis to examine the research question and what association, if any, existed between the importance of leadership characteristics by context (dependent variable) and gender (independent variable). For the research question pertaining to what difference, if any, existed between gender (dependent variable) and self-declaration as a leader (independent variable), the participants who responded “prefer not to answer” were not included in the calculations. Fisher’s exact test was used, with the significance level set at p < 0.05.

Results

A total of 278 physical therapists responded to the questionnaire through snowball sampling. Using that technique, we could not determine how many requests for participation had been forwarded or received. The participants were not required to answer every question. If more than 20.0% of the questionnaire was not completed, the data were not included in the analysis; however, no returned questionnaire reached this threshold.

Study population characteristics

Demographics

Of the participants, 72.7% were female (see Table 1). Most participants reported practising in an outpatient clinic or private practice (45.3%), an acute care or rehabilitation hospital (22.7%), or an academic institution (17.6%). Workplaces were primarily in urban and suburban locations (40.9% and 40.2% respectively); 18.8% of the participants’ workplace locations were in rural settings. Almost half the participants had earned an entry-level (clinical) doctoral degree (57.5%), whereas 12% reported an EdD, DSc, or PhD as the highest degree earned. Approximately 64.2% reported a specialization, and 64.5% were members of APTA.

Table 1 .

Demographic Characteristics of Participants

Characteristic	No. (%) of participants*
Gender (n = 278)
Female	202 (72.7)
Male	70 (25.2)
Prefer not to answer	6 (2.2)
Time since earning entry-level degree, y (n = 274)
Median (range, min–max)	17 (1–44)
APTA member (n = 276)
Yes	178 (64.5)
No	98 (35.5)
Highest degree earned (n = 275)
Certificate	2 (0.7)
Bachelor’s	26 (9.5)
Master’s	51 (18.5)
Clinical doctoral	158 (57.5)
EdD, DSc	12 (4.4)
PhD	21 (7.6)
Other	5 (1.8)
Specialization (n = 274)
Yes	176 (64.2)
No	98 (35.8)
Practice location (n = 276)
Rural	52 (18.8)
Urban	113 (40.9)
Suburban	111 (40.2)
Practice environment (n = 278)
Acute care or rehab hospital	63 (22.7)
Academic institution	49 (17.6)
Outpatient clinic or private practice	126 (45.3)
Other	40 (14.4)

Note: Percentages may not total 100 because of rounding.

^*Unless otherwise specified.

APTA = American Physical Therapy Association.

Self-identification as a leader

Nearly 94.0% of the participants self-identified as a leader (see Table 2). Of this group, more than 56.0% rated attaining a leadership position as extremely or very important to their sense of career success, and 27.3% were neutral as to its importance. Slightly more than half (51.8%) responded that they had formal leadership training, and 61.5% had informal leadership training. APTA and other organization-sponsored continuing education was indicated as the most frequent type of formal leadership training.

Table 2 .

Leadership Background of Participants

Background	No. (%) of participants
Leader (n = 277)
Self-identified as a leader	261 (94.2)
Did not self-identify as a leader	16 (5.8)
Importance of attaining leadership position to sense of overall career success (n = 278)
Extremely important	49 (17.6)
Very important	107 (38.5)
Neutral	76 (27.3)
Not very important	39 (14.0)
Not at all important	7 (2.5)
Formal leadership training (n = 274)
Yes	142 (51.8)
No	132 (48.2)
Informal leadership training (n = 275)
Yes	169 (61.5)
No	106 (38.5)

Demographic traits by gender

To determine the association between the importance of leadership characteristics by context (dependent variable) and gender (independent variable), χ² was computed. The ratings of the level of importance of self-regulation or self-management in the workplace context (χ²₂ = 6.030, p = 0.049) between men and women were statistically significant. In addition, we found statistical significance of extroversion in the context of society between male participants and those who preferred not to answer (χ²₂ = 6.439, p = 0.040). No statistical significance was found in the post hoc analysis of pairwise comparisons for gender adjusted with Bonferroni corrections for self-regulation or self-management in the workplace setting or for extroversion in the society setting.

To understand the relationship of gender to the identification of self as a leader, Fisher’s exact test was completed using the binary groupings of gender. There was no statistically significant relationship between gender and self-identification as a leader.

Leadership characteristics by context

The importance of all leadership characteristics across the three settings is shown in Table 3. Overwhelmingly, leadership characteristics were rated as neutral, important, or extremely important regardless of context – workplace, health care system, or society. No more than 7.0% of the participants rated any characteristic in any context as not very important or not at all important. Of the five characteristics rated most highly as extremely important, the participants agreed that communication and professionalism were either the most or the second most important characteristics across all contexts (see Table 4).

Table 3 .

Leadership Characteristics Rated by Physical Therapists (N = 278^*) in the United States in the Workplace, Health Care System, and Society Contexts

Characteristic (in alphabetical order)	No. (%) of responses
	Extremely important	Very important	Neutral	Not very important	Not at all important
Active management
Workplace†	165 (59.6)	103 (37.2)	9 (3.2)	0 (0.0)	0 (0.0)
Health care‡	136 (49.3)	120 (43.5)	18 (6.5)	1 (0.4)	1 (0.4)
Society‡	74 (26.8)	128 (46.4)	66 (23.9)	6 (2.2)	2 (0.7)
Adaptability
Workplace	215 (77.3)	61 (21.9)	2 (0.7)	0 (0.0)	0 (0.0)
Health care	197 (70.9)	74 (26.6)	5 (1.8)	1 (0.3)	1 (0.4)
Society	138 (49.6)	111 (39.9)	25 (9.0)	4 (1.4)	0 (0.0)
Business acumen
Workplace†	84 (30.3)	145 (52.3)	44 (15.9)	4 (1.4)	0 (0.0)
Health care‡	99 (35.9)	125 (45.3)	49 (17.8)	2 (0.7)	1 (0.4)
Society‡	43 (15.6)	106 (38.4)	113 (40.9)	10 (3.6)	4 (1.4)
Communication
Workplace§	246 (89.8)	27 (9.9)	1 (0.4)	0 (0.0)	0 (0.0)
Health care§	208 (75.9)	62 (22.6)	3 (1.1)	1 (0.4)	0 (0.0)
Society¶	173 (62.9)	80 (29.1)	20 (7.3)	2 (0.7)	0 (0.0)
Credibility
Workplace	200 (71.9)	76 (27.3)	2 (0.7)	0 (0.0)	0 (0.0)
Health care	166 (59.7)	99 (35.6)	11 (4.0)	2 (0.7)	0 (0.0)
Society	108 (38.8)	136 (48.9)	28 (10.1)	5 (1.8)	1 (0.4)
Delegation
Workplace¶	158 (57.5)	109 (39.6)	8 (2.9)	0 (0.0)	0 (0.0)
Health care§	123 (44.9)	122 (44.5)	24 (8.8)	2 (0.7)	3 (1.1)
Society‡	60 (21.7)	121 (43.8)	7 (2.5)	13 (4.7)	7 (2.5)
Empathy
Workplace†	180 (65.0)	91 (32.9)	5 (1.8)	1 (0.4)	0 (0.0)
Health care	147 (52.9)	106 (38.1)	20 (7.2)	3 (1.1)	2 (0.7)
Society†	135 (48.7)	104 (37.5)	33 (11.9)	4 (1.4)	1 (0.4)
Extroversion
Workplace	67 (24.1)	137 (49.3)	57 (20.5)	15 (5.4)	2 (0.7)
Health care	57 (20.5)	124 (44.6)	79 (28.4)	15 (5.4)	3 (1.1)
Society	47 (16.9)	112 (40.3)	95 (34.2)	17 (6.1)	7 (2.5)
Motivating
Workplace‡	210 (76.1)	62 (22.5)	4 (1.4)	0 (0.0)	0 (0.0)
Health care¶	139 (50.5)	121 (44.0)	14 (5.1)	1 (0.4)	0 (0.0)
Society‡	96 (34.8)	126 (45.7)	49 (17.8)	5 (1.8)	0 (0.0)
Professionalism
Workplace‡	234 (84.8)	39 (14.1)	1 (0.4)	1 (0.4)	1 (0.4)
Health care¶	229 (83.3)	40 (14.5)	4 (1.5)	0 (0.0)	2 (0.7)
Society‡	182 (65.9)	69 (25.0)	23 (8.3)	0 (0.0)	2 (0.7)
Self-awareness
Workplace†	140 (50.5)	107 (38.6)	27 (9.7)	2 (0.7)	1 (0.4)
Health care†	115 (41.5)	107 (38.6)	47 (17.0)	6 (2.2)	2 (0.7)
Society‡	103 (37.3)	106 (38.4)	56 (20.3)	9 (3.3)	2 (0.7)
Self-regulation or self-management
Workplace‡	182 (65.9)	86 (31.2)	7 (2.5)	1 (0.4)	0 (0.0)
Health care**	150 (54.9)	101 (37.0)	18 (6.6)	2 (0.7)	2 (0.7)
Society§	130 (47.4)	97 (35.4)	41 (15.0)	5 (1.8)	1 (0.4)
Social dominance
Workplace	86 (30.9)	118 (42.4)	58 (20.9)	15 (5.4)	1 (0.4)
Health care	79 (28.4)	121 (43.5)	61 (21.9)	14 (5.0)	3 (1.1)
Society†	61 (22.0)	93 (33.6)	98 (35.4)	20 (7.2)	5 (1.8)
Social skills
Workplace¶	171 (62.2)	97 (35.3)	6 (2.2)	1 (0.4)	0 (0.0)
Health care¶	135 (49.1)	110 (40.0)	26 (9.5)	3 (1.1)	1 (0.4)
Society¶	131 (47.6)	111 (40.4)	29 (10.5)	3 (1.1)	1 (0.4)
Vision
Workplace†	123 (44.4)	129 (46.6)	24 (8.7)	1 (0.4)	0 (0.0)
Health care†	142 (51.3)	106 (38.3)	25 (9.0)	3 (1.1)	1 (0.4)
Society‡	88 (31.9)	122 (44.2)	55 (19.9)	8 (2.9)	3 (1.1)

^*Unless otherwise specified.

^†n = 277.

^‡n = 276.

^§n = 274.

^¶n = 275.

^**n = 273.

Table 4 .

Five Most Highly Rated Leadership Characteristics Identified as Extremely Important by Physical Therapists as ranked in the Workplace

Characteristic	Definition	Rating (%)
		Workplace	Health care system	Society
Communication	Convey information in a clear and concise manner and be receptive to feedback to facilitate constructive interaction	89.8	75.9	62.9
Professionalism	Align personal and organizational conduct with ethical and professional standards	84.8	83.3	65.9
Adaptability	Deal with change and adversity and adjust to different situations	77.3	70.9	49.6
Motivating	Promote a sense of responsibility, help employees excel by being responsive to individual needs	76.1	50.5	34.8
Credibility	Remain up to date on continuing education, able to give guidance or direction to find answers or solutions	71.9	59.7	38.8

Regardless of context, adaptability was ranked in the top five characteristics as being extremely important. Empathy and motivating demonstrated variability across contexts, and empathy ranked among the five characteristics that were most highly rated as being extremely important in the context of society and motivating in the workplace context. Credibility was included as an extremely important characteristic for the workplace and health care system contexts but not for the society context. Self-regulation or self-management was ranked as a top five characteristic rated as extremely important for the health care system but not for the workplace or society.

The frequency data indicate that fewer than 35.9% of physical therapists consistently rated the leadership characteristics of business acumen, social dominance, and extroversion as extremely important across all three contexts (see Table 5). For the leadership characteristic of vision, fewer than 45.0% of the physical therapists rated it as extremely important for the contexts of workplace and society. For the leadership characteristic of self-awareness, fewer than 42.0% of the physical therapists rated it as extremely important for the contexts of the health care system and society.

Table 5 .

Lowest Rated Leadership Characteristics Identified as Extremely Important by Physical Therapists as ranked in the Workplace

Characteristic	Definition	Rating (%)
		Workplace	Health care system	Society
Self-awareness	Know what you are feeling in the moment, and use those preferences to guide your decision making.	50.5	41.5	37.3
Vision	Interpret trends to plan and effectively communicate a direction that extends well into the future.	44.4	51.3	31.9
Social dominance	Gain the respect and attention of others, appear competent, and have a strong influence over others.	30.9	28.4	22.0
Business acumen	Apply business principles, including organizational dynamics and governance, financial management, and strategic planning, to the health care environment.	30.3	35.9	15.6
Extroversion	Demonstrate assertiveness, energy, and optimism.	24.1	20.5	16.9

A one-way analysis of variance was computed to compare the differences in level of importance among the leadership characteristics in each context (dependent variable; with 1 representing not important and 5 representing very important) as rated by physical therapists in different practice settings (acute care or rehabilitation, outpatient, academic, and other; independent variable). Motivation in the workplace context was found to be statistically significant (F_3,262 = 2.906, p = 0.035). A Tukey post hoc test revealed that physical therapists in the outpatient practice setting placed more importance (mean 4.778 [SD 0.436]; p = 0.044) on motivation in the workplace than did those in academia (mean 4.571 [SD 0.5401]).

Discussion

This study represents an essential step in understanding the U.S. physical therapists’ perceptions of the domain of leadership. The conversation about leadership characteristics and KSAs of leadership in health care grows more urgent as physical therapists engage in a growing number of contexts. This study aligns methodologically with research conducted in Canada and Ireland into physical therapists’ perceptions of the importance of leadership characteristics in the workplace, health care system, and society. These studies provide a unique examination of the leadership characteristics that remains relevant today.^8,9 As noted earlier, minimal changes were made to Desveaux and colleagues’ survey to contemporize the leadership characteristics.⁹ These minimal changes will enable researchers to make future comparisons between the similarities and differences in the perceptions of leadership among all three studies, thus extending the conversation about leadership in physical therapy to a broader level.

Communication and professionalism were the only leadership characteristics that more than 60.0% of U.S. physical therapists rated as being extremely important in each context. This finding aligns with those of McGowan and Stokes and Desveaux and colleagues.^8,9 Overall, these findings are not surprising. There is clear evidence of the significance of communication for effective leadership in health care.^8,17,18 Communication has been cited as the “real work of leadership”^19(p.152) and is a noted competency of leadership across multiple models and frameworks of numerous disciplines.^15,20–22

Similarly, professionalism has been noted to be important in leadership development. A Delphi panel created by Lopopolo and colleagues to investigate the leadership, administration, management, and professionalism content that is part of clinical practice and most relevant to new physical therapist graduates indicated the importance of “professional scanning” and “professional involvement” to both skill and knowledge of a physical therapist.²³ As in the case of communication, Sebelski and colleagues confirmed that professionalism was one of the 37 identified very important leadership competencies needed by new DPT graduates and beyond.¹⁵ The findings of the current study confirm that communication and professionalism are integral components of the leadership characteristics needed by physical therapists across contexts.

A criticism of the study of leadership and leadership theory is that as each nuance of the understanding of leadership is revealed, a new theory or school of thought develops.²⁴ This process causes confusion and contributes to a climate in which there is no commonly accepted definition of leadership.^25,26 Within the health care disciplines, a variety of leadership theories can be applied that effectively depend on the context and environment.²⁶ Until recently, there has been little physical therapist–directed research to help shape a common definition of leadership, isolate the pertinent leadership theories and frameworks, or identify the leadership competencies needed by physical therapists.^15,27,28 Fortunately, this body of research continues to grow, and the results of this study add to this evolving discussion.

The components of EI are frequently integrated into leadership theories or models. Goleman and Boyatzis recently updated one prevalent model consisting of four domains (self-awareness, self-management, social awareness, and relationship management) with 12 EI competencies.²⁹ Some of the terminology used to describe the 15 leadership characteristics in this study continue to align directly with these updated competencies, but some do not. For example, this updated EI model uses the terms relationship management and influence rather than social skill and social dominance, which were used in this study.³⁰ These relative differences highlight the evolving nature of leadership theories and frameworks and the importance of explicitly clarifying and standardizing terminology to encourage the development of leadership skills.

Nicol and colleagues suggested that high EI and relationship skills are two of the most important and universally selected attributes that health care leaders need to be successful.¹³ The LEADS Health Leadership Capabilities Framework, identified by the Canadian College of Health Leaders, affirmed that “leading self” requires individuals to be self-aware and able to manage themselves.³¹ Sebelski and colleagues similarly reported that the EI components of self-awareness and self-management, self-confidence, team orientation, and trustworthiness were important to physical therapist practice in the United States.¹⁵

Yet, of the 15 leadership characteristics identified in this study, self-awareness ranked 11th in the workplace, 12th in the health care system, and 8th in society; conversely, self-regulation or self-management ranked 6th, 5th, and 6th, respectively. These findings are not congruent with the integration of EI into current leadership theories and frameworks and may reflect a lack of consensus on how the profession of physical therapy in the United States defines leadership, confusion as to how leadership skills develop, and lack of clarity about the fundamental competencies for effective leadership.

In general, our participants were more likely to rate all characteristics as extremely important in the workplace than as extremely important in society. Physical therapists may more easily recognize the importance of leadership in the workplace than in health care systems or society, where the concept of leadership may seem more elusive.^8,9,10 If this is the case, developing physical therapists’ leadership skills specific to society will need to be prioritized if the profession can achieve APTA’s vision to “transform society by optimizing movement to improve the human experience.”⁷

Health care settings are acknowledged to be complex and dynamic environments. Because we recognized the concept that different settings may necessitate applying different leadership theories and styles,²⁷ we hypothesized that participants’ practice setting would be associated with a difference in their perception of the importance of different leadership characteristics in each context. Interestingly, our findings rejected this hypothesis. Only one difference was noted in motivation between therapists in the academic and outpatient settings. Because this is the first study of U.S. physical therapists to consider this hypothesis, more study is recommended before drawing conclusions.

Without some level of business acumen, physical therapists may find it challenging in practice to advocate for patient services and obtain the resources necessary to provide care. Administration and management (A&M) skills have been identified as essential to physical therapist practice, and specific A&M skills have been identified as critical for the entry-level practitioner.³² Yet the findings from our study reveal that, across all three settings, physical therapists did not perceive business acumen to be an important leadership characteristic. Further exploration of the importance or lack of importance assigned to business acumen is necessary given the interrelationships among quality, cost of care, and payment.

Women represent 80.0% of the health care workforce in the United States, but they remain significantly under-represented in titled leadership roles.^33,34 The current study did not find a relationship between gender and self-declaration as leader. This result supports Sebelski’s findings that physical therapists’ leadership self-efficacy in a variety of leadership KSAs did not differ by gender,¹⁴ but it contrasts with those of Desveaux and colleagues, who found gender to be a significant trait, with men more frequently reporting as self-declared leaders than women.⁹

Our results also differ from those of Johanson,³⁵ in which male students reported statistically significantly higher expectations than female students to own a private practice, become a faculty member, engage in scholarship, or become a manager or administrator. Because much attention continues to focus on the gender imbalance in health care and in health care leadership, this study adds to the body of literature specific to the profession of physical therapy.

Future research is needed in several areas to explore leadership in physical therapy practice. Of utmost importance, research in the health care disciplines needs to examine the constructs of social identity across various contexts and practice settings.³⁶ Elucidating the definition of leadership, or understanding leadership as a concept, may result in less variability and more consistency in teaching, developing, assessing, and researching leadership KSAs;³⁷ this might encourage physical therapists to take on greater responsibility for leadership, thereby transforming health care and society.

Examining the relationship among specialization and other demographic variables may further contribute to physical therapists’ understanding of perceptions of leadership. Research also needs to explore contemporary leadership frameworks and theories, such as transformational and authentic leadership, to indicate how the leadership characteristics and competencies identified within physical therapy from the point-of-care perspective fit into their structures.^38–40

Our study had several limitations. First, there may be limitations related to the study design and bias associated with web-based questionnaires.⁹ Although the number of responses was relatively low, the demographics of the sample relating to gender and practice setting were similar to the current statistics for physical therapists in the United States.⁴¹ Second, the number of participants and the snowball sampling may have captured a sample that was biased toward a more positive perception of leadership by physical therapists because a large number of clinical specialists and members of APTA completed the questionnaire. The contribution of specialization to perceptions of leadership is an topic unexplored with U.S. therapists and was not the intention of the current study.¹⁴

Third, the lack of a common electronic mailing list necessitated choosing snowball sampling to recruit participants. Snowball sampling has several known limitations that may pertain to the sample of this study: finding participants and starting a referral chain, controlling the eligibility of the participants, and determining the number of participants from a particular referral chain.^16,42

Next, the terminology used to describe the 15 leadership characteristics in this study does not uniformly align with updated models or competencies. For example, the cultural implications of using the term social dominance instead of social influence are unknown, and physical therapists in the United States may interpret this term differently than physical therapists in Canada, which may subsequently affect the results.

Finally, although this study addressed gender, we did not consider other social identities that are known to be associated with perceived expertise and leadership. As noted earlier, social systems and related networks of relationships such as racism are an area for future consideration.^43–45

Conclusions

The findings of this study further the discussion of leadership in the profession of physical therapy in the United States and show that a comprehensive acceptance of leadership characteristics is important regardless of practice setting and context. Further studies need to explore the role of gender and other social systems on an individual’s self-declaration as a leader. Identifying essential leadership characteristics, frameworks, and theories will be necessary for the positive transformation of health care delivery, patient outcomes, and population health. Further work will be necessary to transition from declaring the importance of leadership skills identified in this study to identifying the essential leadership skills that need to be integrated into physical therapists’ education and clinical practice.

Key Messages

What is already known on this topic

Culture influences perceptions of leadership. Physical therapists in Canada and Ireland have similar perceptions of leadership characteristics that are important for effective leadership. Canadian physical therapists may perceive themselves as leaders more than do Irish physical therapists. Illuminating greater awareness of perspectives related to leadership may assist physical therapists’ ability to move forward as a profession in different health care systems and societies.

What this study adds

Results from this study add to the understanding of U.S. physical therapists’ perceptions of the domain of leadership while adding to the potential for an expanded cross-cultural comparison of leadership perceptions among physical therapists worldwide. This study provides further support that communication and professionalism are extremely important leadership characteristics as perceived across three different cultures. Results also highlight the significance of clarifying and updating terminology associated with evolving definitions of leadership. Further investigation to construct a universal definition of leadership for physical therapists may guide greater integration and development of leadership competencies globally.