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POSITION PAPER

Servant-Leadership: A Philosophical Foundation for Professionalism in Physical Therapy

Gersh, Meryl Roth, PT, MMSc

Author Information
Journal of Physical Therapy Education: October 2006 - Volume 20 - Issue 2 - p 12-16

Abstract

INTRODUCTION

An overarching focus of the physical therapy profession during the past 5 years has been the definition, development, enrichment, and inculcation of professionalism among physical therapists and physical therapist students. As early as 1955, the Dictionary of Occupational Titles, cited by Plack and Wong,1 defined physical therapists as professionals. Characteristics of professionals include “rigorous training that culminates in mastery of a clear and distinct body of knowledge, expertise within and contribution to that body of knowledge, and adherence to a specific code of ethics that governs autonomous professional behavior.”1(p48) Implicit in this definition are the obligations of essential service to the public, social and political activism, and advocacy.

During the past 50 years, the physical therapy profession has evolved from an allied health profession in which physical therapists cared for patients/clients under the direct prescription from a physician, to a doctoring profession in which professionals deliver physical therapy services without requiring a physician's referral or prescription. The public now has direct access to physical therapy services in 38 states. Physical therapists serve as an entry point into the health care system. During the last session of the United States Congress, bills to approve direct access to physical therapy services for Medicare beneficiaries instigated heated debate. This professional evolution provides both enhanced practice opportunities and, more important, an awesome responsibility to offer optimal service with the highest commitment to ethical practice and leadership. Physical therapists now must lead by example, collaborate with other leaders to enhance health care delivery, advocate for patients, empower patients to self-advocacy, and, above all, model the ideals associated with professionalism and ethical leadership and practice. As professional education programs for physical therapists transition to the clinical doctoral degree (DPT), the challenge to prepare physical therapist students for the moral, ethical, professional, and clinical challenges that they will confront is incumbent upon physical therapist educators and academic administrators. Ultimately, in conferring the title of Doctor on our graduates, the profession holds the stewardship of the public's trust.

Recent development of official documents to guide the professional evolution of physical therapy in the 21st century highlights the focal point that professionalism plays. In 2000, the American Physical Therapy Association (APTA) adopted the Vision Statement for Physical Therapy 20202 that clarified the scope and breadth of physical therapist practice, the foundation of doctoral-level preparation, a commitment to integrity, life-long learning, accessible health care for all people, and evidence-based practice. In his 2003 presidential address, then-APTA President Ben Massey Jr, PT, MA3 revealed that the APTA Board of Directors had unanimously identified professionalism as the key to achieving Vision 2020.

Other recently updated documents that historically set standards for values, behavior, and practice throughout the physical therapy profession, including the APTA Code of Ethics,4APTA Standards of Practice5 and APTA Guide for Professional Conduct,6 echo the foundational principles of professionalism documented in more recently developed works. In an attempt to further define the set of attributes and behaviors that communicate professionalism, a consensus conference hosted by APTA in July 2002 identified the core values of the profession: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility.7 According to Bezner,8 these values will be integrated into the profession's documents that guide our education and practice.

As we examine the values that anchor professionalism in physical therapy, themes of service, patient/client-focused care, collaborative partnership, integrity, respect, empowerment, and advocacy emerge. These themes are remarkably consistent with those proposed in the philosophy of servant-leadership, initially defined by Robert Greenleaf in 1970.9 Greenleaf defined servant-leadership as the conscious choice to serve first, to select others' needs as the highest priority.9(p7) Servant-leaders envision and act from a “base of humility, empathy, compassion, and commitment to ethical values.”10

The tenets of servant-leadership offer a unifying matrix for the enhancement of professionalism and the focus of professional behaviors in physical therapy. This paper will affirm that the ideals embodied in servantleadership form a philosophical foundation for professionalism in physical therapy for the 21st century.

Servant-Leadership

In 1970, Robert Greenleaf first introduced his philosophy of servant-leadership. He proposed that people bestow leadership on those people identified as servants first, those who have made a conscious choice to place others' needs as their highest priority.9(p2) Greenleaf came to this realization after reading Hesse's The Journey to the East,11 a description of a mythical journey by a group of people on a spiritual quest.12(p3) Greenleaf asserted that leadership grows out of service, that great leaders are servants first.9(p2) He proposed that effective leadership is measured by whether “those served grow as persons, when they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants.”9(p7) Gardiner13 extended that growth from autonomy (independence) to interdependence and ultimately to wholeness.

The raison d'être of a doctoring profession such as physical therapy is the service of our patients/clients, the focus on assistance, empowerment, autonomy, and ultimately wholeness. Greenleaf described the process of making whole as healing.9(p27) As physical therapists contribute to the healing of our patients/clients, we become whole ourselves. Greenleaf suggested that “there is something subtle communicated to one who is being served and led, if, implicit in the compact between servant-leader and led, is the understanding that the search for wholeness is something they share.”9(p27) Thus the servant (leader) and served grow whole from this mutually empowering relationship.

Greenleaf described foundational elements of servant-leadership. Servant-leaders listen receptively, reflect on what they hear, and welcome communication.14(p313) Such openness conveys empathy, “the imaginative projection of one's own consciousness into another being,” which further enhances trust and acceptance between servant and served.9(p12) Greenleaf indicated that in servant-leadership, “trust is first. Nothing will move until trust is firm.”14(p101) These tenets of servant-leadership are instrumental for the effective caring of patients.

Servant-leaders articulate a vision, a goal, and a dream, based on values that their followers trust.9(p9) The vision grows out of a broad-based conceptualization that looks beyond day-to-day realities.12(p6) Servant-leaders practice awareness, described as the expansion of perception, the development of an ability to observe, place in context, gain perspective, develop insight, and listen to the “still small voice within.”9(pp19-20),12(p5) Such awareness enhances foresight, “the lead that the leader has.”9(p18) Foresight requires one to be historian, contemporary analyst, and prophet simultaneously, contributing to an intuitive leader's creative decision making with acceptable risk.9(pp16-17) Such risk is acceptable to the followers because they trust the ethical leader to have considered the consequences of the decision prior to action. Frick summarized a servant-leader as “one who is servant first and acts with integrity, foresight, intuition, a dedication to consensus, and a sense of history.”15

Servant-leaders rely on persuasion, voluntary assent based on trust and founded on legitimate power, to influence followers, rather than on coercion, compulsion based on authoritarian or positional power.9(p21) Persuasion invites those served to participate in the decision-making process, leading to consensus, a powerful community-building force. Greenleaf presented the concept of community as foundational to servantleadership: “Any human service where he who is served should be loved in the process requires community, a face-to-face group in which the liability of each for the other and all for one is unlimited.”9(p29) Unlimited liability for one another promotes trust and legitimacy, both critical to a nurturing relationship between physical therapist and patient, and requisite for the advancement of our profession.

Individual trust extends to the public trust, a defining component of a profession. The primary commitment to serving the needs of others in an environment of public trust elevates a profession to the responsibility of stewardship, “the willingness to be accountable for the well-being of the larger organization [public] by operating in service rather than in control, of those around us.”16(p85) Thus, a hallmark of the physical therapy profession is the provision of service to the community while honoring the stewardship of the public trust bestowed upon us. The valuing of such responsibility embraces the essence of professionalism.

PROFESSIONALISM

Defining Professionalism

Defining professionalism challenges health care practitioners, educators, researchers, ethicists, administrators, and students across disciplines. Often the definition takes on the “I know it when I see it” character, suggesting an outward demonstration of behaviors associated with integrity, caring, knowledge, skill, and ethical practice. Carey and Ness offered that professional behavior demonstrates “honesty, courage, and continuous regard for all.”17(p20) They further defined professionalism as a demonstration of “attitudes and behaviors that portray the traits endeared by a specialized discipline of study and practice.” While the media often focus public attention on health care costs, reimbursement, and inward-focused consumerism, Carey and Ness reminded us that “professionalism is projected outwardly for the good of the patient.”17(p21)

Hill18 described 10 traits of professionalism for pharmacists as:

  1. Knowledge and skills.
  2. Self-improvement.
  3. Service.
  4. Pride in the profession.
  5. Covenantal client-provider relationship.
  6. Creativity.
  7. Trustworthiness.
  8. Accountability.
  9. Ethical decision making.
  10. Leadership.

In 1998, the Pew Health Professions Commission defined 21 competencies to carry the health professions into the 21st century. Eight of these directly addressed the “otherfocused” characteristics of servant-leadership: social responsibility, ethical behavior, improved access to health care, relationshipcentered care of individuals and families, cultural sensitivity, leadership development, advocacy, and life-long learning for self and others.19 The Commission urges all health care professionals to integrate these competencies into their education and service practices as health care evolves.

Assimilating the ethos of a profession is central to the development of professionalism. Stiller defined ethos as “the distinguishing characteristics, sentiments, and beliefs of [a] profession that guide the behavior of practitioners.”20(p7) She built a theoretical ethos model with a core of enduring traits, surrounded by evolving characteristics that are influenced by changes from within and outside the profession, and contained with the systems of health care and society.20(p13) Stiller discovered that service was the keystone of the enduring traits. Physical therapists entered the profession to help people “be the best they can be.” Senior leaders in physical therapy described the values of the profession as “ones of providing service to others, caring for others, helping others to become as independent and functional as they could become … and actually those core values persist today.”20(p9) The enduring traits emphasized caring, hard work and dedication, warmth and openness, and a positive attitude, all characteristics of servant-leaders.

The core documents of the profession also reflect its professional ethos. Table 1 summarizes a comparison between the characteristics of servant-leadership and the principles of professionalism reflected in the core documents. The APTA Code of Ethics4 defines principles for the ethical practice of physical therapy. The APTA Guide for Professional Conduct6 interprets the Code of Ethics by describing ethical professional conduct. Principle 1 in both documents asserts the primacy of respect for individuals and the provision of compassionate care, reflecting the characteristic of empathy in servantleadership. Principle 2 exhorts physical therapists to act in a trustworthy manner towards patients/clients, recalling the stewardship required of servant-leaders. This stewardship of the public trust extends to Principle 9, “physical therapists shall protect the public and the profession from unethical, incompetent, and illegal acts.”4,6 Principle 10 directs physical therapists to address the health needs of society through pro bono service and other activities that benefit the health status of the community. This principle reminds us that physical therapists are servants first, promoting health and healing by empowering their patients to achieve optimal function and wellness. Physical therapists conceptualize the current and future health needs of the community, and respond to those needs through community-building advocacy. The respect for colleagues and other health care professionals required in Principle 11 extends the servant-leadership characteristic of building community to include collaboration with colleagues for the benefit of the public's health. Standard VI of the APTA Standards of Practice5 further describes community responsibility.

Table 1
Table 1:
Servant-Leadership and Principles of Professionalism in Physical Therapy Core Documents

The APTA Standards of Practice5 reiterates the primary focus of service in physical therapy. Standard IIIA emphasizes the collaboration required between physical therapists and patients/clients throughout the rehabilitation process, empowering the patients/clients as primary participants in their rehabilitation and reminding the physical therapists of their first among equals status in this partnership. Greenleaf suggested an organizational structure based upon the Roman primus inter pares, or “first among equals” model, rather than the traditional hierarchical model.14(p74) In patient care, such a model empowers any member of the patient-health care team to serve as first among equals, or leader for a given set of circumstances. The first among equals model also promotes persuasion rather than coercion because hierarchical power is not involved.21 Thus, all team members become empowered to lead legitimately, facilitating consensus.

Covey defined core values as “something at the soul of an organization [that] does not change but will enable people to live with change.”21(p3) In 2002, APTA convened a consensus conference to “define and describe the concept of professionalism by explicitly articulating what the graduate of a physical therapist program ought to demonstrate with respect to professionalism.”7 The conference participants identified the core values of accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility; provided a definition for each; and suggested sample indicators that described physical therapists' behaviors that represented these values. Such behaviors provide external signs that symbolize the internal reality of the values foundational to professionalism.23

The APTA Core Values directly reflect characteristics associated with servantleadership. Accountability is “active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist.”7 McGee-Cooper described accountability as “the rudder that keeps us on course.”24(pp77-78) She extended accountability to patients as well, suggesting that a shared vision, developed between the servants (therapists) and the served (patients), empowers the served to achieve their goals. In such a relationship, “because the vision was shared, because the team created and owned the plan, because the purpose and outcome were believed to be pivotal, this team chose to hold themselves and each other accountable for results.”24(p84)

Altruism, “the primary regard for or devotion to the interest of patients/clients,”7 exemplifies the focus on others' needs that is the hallmark of servant-leadership and the health care professions.9(p7),25 “Compassion, the desire to identify with or sense something of another's experience, and caring, the concern and consideration for the needs and values or others”7 reflect the empathy embraced by servant-leaders.9(p12) The ethical practice embodied in integrity represents the moral code described by Covey,22(p5) inherent in individuals who practice servant-leadership.

Professional duty mirrors the commitment to serving individual patients/clients, the profession, and society. Once again, the servant-leadership principle of service first echoes throughout the profession.9(p2) Social responsibility, defined as “the promotion of a mutual trust between the profession and the larger public that necessitates responding to societal needs for health and wellness,”7 heralds servant-leadership's stewardship of the public trust and the collaborative relationship between servant-leader and served.12(pp6-7) While excellence concerns more specifically the role diversity, selfregulation, body of knowledge, and commitment to life-long learning that professionalism in physical therapy requires, the commitment to excellence in order to more effectively serve patients also fits well within the servant-leadership model.

The evolution of the APTA core documents during the past 5 years reflects the vision for physical therapist practice in the year 2020.2 Physical therapists who are professionally educated at the doctoral level will be recognized by consumers and other health care professionals as the practitioners of choice for the comprehensive management of patients/clients with health care needs related to movement, function, and health. Physical therapists believe that the practice changes envisioned for 2020 will enhance their practice in the patient/client-focused way characteristic of a health service profession.26 Physical therapists will collaborate with their patients/clients in a partnership throughout the rehabilitation process that will empower patients/clients toward a new level of function, independence, responsibility, and advocacy. Such a collaborative relationship between physical therapist and patient/client epitomizes servant-leadership, revealing its tenets as the common threads in the advancement of professionalism for the 21st century.

Ethics and Professionalism

The core documents that guide our professional practice delineate principles and behaviors that call upon an intrinsic moral value system. In 2000, Romanello and Knight-Abowitz27 focused the ethics debate on care. Tong, cited by Romanello and Knight-Abowitz, reframed ethics as a relationship, rather than a set of rules:

There are two parties in any relation: the first member is the “one caring”; the second is “the cared for.” The one-caring is motivationally engrossed or displaced in the cared-for. S/he makes it a point to attend to the cared-for in deeds as well as in thoughts. When all goes well, the cared-for actively receives the caring deeds of the one-caring, spontaneously sharing his/her aspirations, appraisals, and accomplishments with him/her.27(p20)

Such a reframing fits well with the servantleadership model as it represents a dynamic reciprocity between the cared-for (served) and the one caring (servant-leader). The ethic of care sensitizes physical therapists to patients'/client's deepest values, enabling a more empathetic response that “compels the practitioner to construct this relationship with the patients/clients as subjects, rather than objects, of the healing encounter.”27(p21) Additionally, this reciprocal relationship reminds the practitioner of the obligation to grow as well. Greenleaf observed that “humility in the more powerful is ultimately tested by their ability to learn from and gratefully receive the gifts of the less powerful…. One may not safely give unless one is open and ready to receive the gifts of another.”14(pp320,324-325)

Covey echoed this dynamic reciprocity: “Moral authority is another way to define servant-leadership because it represents a reciprocal choice between leader and follower. If the leader is principle-centered, he or she will develop moral authority. If the follower is principle-centered, he or she will follow the leader…. [Both] follow truth. They grow to trust one another. Moral authority is mutually developed and shared.”22(pp5-6)

The development of strong moral character, or virtue ethics, is tantamount to the development of professionalism. Purtilo extended the ethic of care to the practice of moral courage, that which is required when care is threatened. She defined moral courage as “a readiness for voluntary, purposive action in situations that engender realistic fear and anxiety in order to uphold something of great moral value.”28(p4) Today, this means caring for our patients/clients in an other-focused rather than self-focused health care environment.

Romanello's27 ethic of care reflected the patient/client-centered focus of service, and the empowering partnership inherent in servant-leadership. Purtilo28 incorporated the principles of conceptualization, foresight, and stewardship as she exhorted physical therapists to demonstrate moral courage when the care of patients/clients, our service, is threatened. Clearly, the ethics and ethos of the physical therapy profession represent the gestalt of servant-leadership.

Leadership and Professionalism

Central to the development of professionalism is leadership that instructs, empowers, and nurtures; in a word, serves. Leaders promote learning in individuals and organizations.29 In his noteworthy treatise, Leadership Is an Art, Max DePree proposed, “The signs of outstanding leadership appear primarily among the followers. Are the followers reaching their potential? Are they learning? Serving? … Do they change with grace?”30(p12) He suggested that effective leaders are stewards, not owners. “They should leave behind them assets and a legacy.”30(p13) In the physical therapy profession, the empowerment of our patients/clients to realize their optimal potential, to participate fully in their healing, and to grow sufficiently confident and knowledgeable to advocate for their own health care needs represents this legacy. We nurture students to become generous, effective care providers and future servant-leaders. “Preparing those of the young who are capable of it for responsible roles as servants” is a requisite of servant-leadership.14(p135)

Schmoll31 offered that servant-leaders in physical therapy envision dreams that unite people to move organizations forward. They lead from among a group of peers, as firsts among equals rather than as chiefs. DiGiacomo32 asked current leaders in physical therapy to describe effective leadership characteristics. Leaders inspired and motivated people to act. They communicated effectively, using persuasion rather than coercion. Hack, president of the APTA Education Section, emphasized mentorship, noting that “other people's growth matters…. Leaders play an important role in allowing someone else to succeed.”32(p52) Vision, foresight, courage, and a willingness to take risks after considering the possible consequences also characterized effective leaders in physical therapy.32(pp54-55),33

El-Din effectively described leadership characteristics in physical therapists, citing hallmarks of servant-leadership in effective leaders. Leaders orient those they serve toward change: “The leader best empowers others to make the changes by constant awareness of self and a focus on what matters.”34(p25) El-Din continued by identifying what matters in leadership: empathy, reflective listening, kindness, patience, respect, integrity, moral courage, vision, participatory relationships between therapist and patient/client, between teacher and student, between peers.34(pp26-27) Servant-leaders are sensitive to the readiness of the followers. She pointed out, “When the student is ready, the teacher appears.”34(p26) Finally, El-Din poignantly clarified the essence of servant-leadership in education: “Teaching is the most complex leadership role of all. By its nature, it permits an individual access to another with the potential to change that individual forever. It is a special, privileged state.”34(p26)

In her editorial “A Compassionate Partnership” Deusinger35 highlighted the principles of servant-leadership inherent in the therapeutic relationship that evolves between a patient/client and physical therapist. She described a partnership that assists the patient/client toward improved health and independence based upon an assumption of compassion and shared responsibility between the physical therapist and the patient/client. She emphasized that we learn much from our patients/clients as we create a partnership that maximizes freedom of choice. Deusinger concluded, “Now is the time for all of us to build a climate of compassion and excellence in interpersonal relationships and to seek stronger partnerships with our patients so that their health outcomes are maximized and their ability to continue pursuing health is fostered.”35(p2) Deusinger's words reflect the pinnacle of professionalism rooted in the precepts of servant-leadership. Leadership in physical therapy, as a characteristic of professionalism and a tool to enhance professionalism, embodies the doctrine of servant-leadership in its purest form.

CONCLUSION

Leaders in physical therapy have designated professionalism as the keystone for the advancement of Vision 2020 in the 21st century.3 Toward this end, APTA has developed core documents to define the values and behaviors that reflect professionalism. Explicit in these core documents are behaviors that demonstrate empathy, trust, compassion and caring, community building, and the empowerment of those served. These behaviors also reflect the principles of Greenleaf's servant-leadership,9 which focuses on the primacy of others' needs, the partnership between the servant-leader and the served, and the growth and empowerment of those served in the process of such leadership As such, servant-leadership provides a powerful philosophical foundation for professionalism in physical therapy.

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Keywords:

Physical therapy; Professionalism; Servant-leadership; Ethics; Core values

Copyright2006 (C) Academy of Physical Therapy Education, APTA