Nearly a half million of Americans' deaths1 are due to medical errors from a health care system that spends more per capita on health care than any country. Despite the Institute of Medicine's call to action in 1999, health care institutions continue to struggle to improve patient safety and quality.2 A direct link exists between the quality of leadership and quality of care.3,4 Organizations such as The Joint Commission,5 the Agency for Health care Research and Quality,6 and the National Center for Health care Leadership7 have focused on the need for greater leadership engagement in quality and safety improvement as a strategy to improve care and ultimately patient outcomes. However, despite these initiatives, papers and reports continue to indicate that the health care processes and systems remain inefficient, error laden, and costly.8,9
Leadership development efforts have focused on individuals who hold formal leadership positions in health care organizations.10–12 Although there is evidence to support that explicit leadership development is correlated with enhanced patient experiences, improved quality of care, and organizational performance,13–22 the impact of training at the executive levels of organizations has not resulted in the needed transformation of the health care system. Engagement of point-of-care professionals is essential in the change process to truly appreciate significant cost savings and improved patient outcomes.23,24 Yet, frontline health care professionals are rarely the focus of leadership development, and few programs systematically address leadership behaviors and skills.4
REVIEW OF LITERATURE
In the United States, medicine and nursing25–29 have worked to identify leadership competencies required for professionals to lead change across health care, but this work has not yet led to consensus adoption of specific competencies in the entry-level curricula. By contrast, the core competencies for interprofessional collaborative practice include prelicensure through several career stages of development.30 In the physical therapy profession, the American Physical Therapy Association (APTA) has acknowledged the importance of leadership within physical therapy as evidenced by supporting resources and multiple pathways for leadership development. Specifically, HPA the Catalyst, the section on Health Policy and Administration of the APTA offers courses directed at the development of leadership skills for practicing individuals. Four academies of the APTA have published core competencies for the entry-level graduate specific to a topic area or patient population.31–34 Of these, only the 2011 Neurologic entry-level curricular content document33 from the Academy of Neurology states that a graduate should be able to “describe necessary leadership skills” for practice.
The Commission on Accreditation for Physical Therapy Education (CAPTE) has few references addressing leadership in physical therapist entry-level academic standards.35 Rather than identifying minimal leadership skills and behaviors in entry-level DPT education, CAPTE lists skills and behaviors found in leadership frameworks of other professions. Skills and behaviors indicative of leadership are not specifically labeled as such in the CAPTE standards and elements. For example, Standard 7 includes communication skills broadly and not within the context of leadership.35 The Clinical Performance Instrument, developed by the APTA and used by most DPT programs to assess clinical performance, explicitly lists leadership as “beyond entry-level.”36 The American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) recently adopted core competencies.37 The core competencies describe expectations for residents newly admitted to the program and on its completion. Leadership is not identified as a core competency. It is listed as a behavior. For the behavior of leadership, the incoming resident should “recognize the characteristics of an effective leader and collaborator.”37 On graduation, the resident should “integrate leadership skills to advance the physical therapy profession.”37 The ABPTRFE document indicates that leadership development is a postprofessional physical therapist skill set.
Role reframing has been identified as essential for role expansion within physical therapist entry-level curricula for graduates to be prepared to enter a dynamic and chaotic health care work environment.38 Employers and practice owners are more strident with expectations that new physical therapist graduates demonstrate fundamental leadership behaviors in roles as clinicians, team members, advocates, and consultants.39 Current physical therapist entry-level doctoral education is inconsistent on if and how much explicit emphasis is placed on the development of leadership skills that transfer to the workplace. Given that the profession has not collectively defined leadership or the critical graduate competencies related to leadership, academic programs have little systematic and clear guidelines on which to develop leadership frameworks within curricula. There is wide variation among the APTA, APTA sections/academies of specialty practice, CAPTE, and entry-level education in addressing leadership that underscores the inconsistent expectations of leadership competencies for the entry-level graduate.
This lack of explicit understanding and clear development of leadership skills and competencies is a critical gap in entry-level physical therapist curricula. Leadership development in other health care professional entry-level curricula notes that competencies, if identified, have not been consistently standardized thus challenging the ability to assess the effectiveness of graduates in practice.4,29 Little is also known regarding academic physical therapist faculty's impressions on the importance of leadership development in entry-level curricula or their knowledge and skills related to curricular design and teaching on the topic of leadership. These voids can also lead to challenges with translation of leadership skills from curricula to point-of-care physical therapy health services. An urgent need exists for academic programs, physical therapy faculty, and professional organizations to define leadership, identify competencies related to knowledge, skills, and behaviors necessary for physical therapist graduates to enter the workplace, and if advanced leadership skills are needed in physical therapists across the continuum of their careers.
Physical therapists are essential members of interprofessional teams in the health care continuum who impact the quality of care delivered to patients and clients and who have a professional responsibility for transforming the health and wellness of society. Development of a framework to explicitly address point-of-care leadership competencies in physical therapists is critical to the profession's ability to influence and affect change. The primary purpose of this paper was to inform this gap in understanding expectations of leadership development that currently exists in DPT entry-level education and for point-of-care physical therapists early in their professional practice.
Delphi Panel of Content Experts
Selection of the Delphi panelists was based on predetermined criteria for content expertise in leadership as demonstrated by: 1) licensure as a physical therapist with an area of paper within health care leadership; 2) evidence of scholarship within the area of leadership; and/or 3) evidence of professional and contemporary knowledge of leadership literature. The possible candidates to populate the Delphi panel consisted of physical therapists involved in the development and teaching of leadership courses/programs, physical therapist academic leaders who participated in formal leadership development education, and/or physical therapists who had been or are currently in leadership positions of health care environments who had formal leadership development education. Of the 30 physical therapists identified, a rolling outreach to the potential panelists sought diversity in age, sex, ethnicity, degrees attained, leadership development education, and primary professional roles. All targeted panelists were contacted through email for consent and subsequent participation in the survey. The Delphi panelists were not identified to each other.
The Delphi process through an electronic survey instrument was used as the paper design for this project with a respondent group, the “Delphi panelist” populated by physical therapists who met the inclusion criteria and agreed to participate. The Delphi method has been described as helpful for researching topics where there is incomplete knowledge, the view on the topic is unknown, or there is limited consensus.40 Four key characteristics41 of the original concept of Delphi method were integrated into this paper: 1) anonymity of participants to encourage them to express their opinions; 2) controlled feedback from the researchers between rounds to inform participants of the variety of views emerging from among the sample; 3) iteration to allow them to consider, reevaluate, and clarify or modify their views; and 4) aggregation of panelist's responses, that allows for analysis and interpretation of data.40 The paper was approved by the institutional and ethics review boards of Saint Louis University, College at Brockport - SUNY, Clarkson University, and University of Vermont.
Collation of the Leadership Competencies
An intensive literature search was facilitated by a medical librarian with the SCOPUS and WorldCat databases. Search terms or the appropriate derivatives for the database included “leader,” “develop,” “competency,” “behavior,” “skill,” and “characteristics.” Additional resources including gray literature were considered to ensure that contemporary resources and longstanding contemporary evidence that fell outside of the literature search were included for discussion. Inclusion criteria to identify primary competency resources included 1) developed in the United States and 2) focused on health care professions. The authors identified 4 primary competency resources that identified explicit leadership behaviors and/or skills: Health care Leadership Alliance Competency Model and Competency Directory (v2.0)26; National Center for Health care Leadership Competency Model (v2.1)25; Core Competencies for Interprofessional Collaborative Practice: 2016 Update30; and Student Leadership Competencies.42
Collation of the Leadership Competencies
The authors engaged in several rounds of deliberations to collate the listing of potential leadership competencies for consideration by the Delphi panelists. The authors combined their experiences and content expertise gained through formal advanced doctoral education in higher education administration, leadership, curriculum, and physical therapy; achievement of masters' in business management and administration; and extensive experience in academic faculty, leadership, and clinical leadership roles to provide the expertise for the task of collation of the leadership competencies. Several competencies listed in the resources overlapped with each other and that of other reviewed resources necessitating author discussion and consensus on potential competency titles or definitions. The author group set a predetermined consensus level at 0.80 when deliberating on each of the competencies of leadership and definitions. Those listed competencies that reached consensus by the author group were included in the collated document sent to the Delphi panelists. Competencies were presented to the panelists by placement into the base sentence: “The new graduate (1 year or less postlicensure) physical therapist who does not hold a formal/titled leadership position is [competency].” For example, “accountability,” which was represented in a variety of forms in each of the primary competency resources, was modified to “accountable” per the authors’ consensus process. Similarly, “empathy” was standardized grammatically to “empathetic” for placement in the base sentence. A total of 76 potential leadership competencies were identified and included in the document sent to the Delphi panelists (Figure 1).
The document was distributed from Saint Louis University using QUALTRICS QualtricsTM (Seattle, WA, www.qualtrics.com). The panelists completed 2 rounds. For each knowledge, skills, and behavior of leadership, consensus level for the panelists was set priori at 0.80. In each round, a stem statement was given, and a definition was provided for the knowledge, skill, or behavior of leadership. The panelist indicated the level of importance (very important, somewhat important, or not important) for each competency for a new graduate physical therapist (1 year or less postlicensure) and physical therapists greater than 1 year of licensure.
- For example: The new graduate (1 year or less postlicensure) physical therapist who does not hold a formal/titled leadership position demonstrates integrity (upholds one's self to being honest with strong moral principles).
To capture panelists' nuanced perspectives regarding the competencies, the authors provided an area on the survey instrument for edits and comments after the selection of items. If edits were provided from the panelists in round 1, these were incorporated into round 2 of the Delphi process, and the panelists were asked for the level of importance of the revised item. Competencies that met the level of consensus of 0.80 or greater in round 1 were presented to the panelists in round 2 with the level of consensus reached, the level of importance, and a narrative box for comments or edits for agreement or nonagreement of the level of importance.
- For example: The new graduate (1 year or less postlicensure) physical therapist who does not hold a formal/titled leadership position is accountable (accepts ownership of the responsibility for decisions, roles, obligations, and actions) (100% very important).
Items that did not meet consensus of 0.80 in round 1 were presented again to the panelists in round 2 with the level of consensus from round 1 included for review.
- For example: The practicing physical therapist (greater than 1 year postlicensure) who does not hold a formal titled leadership position demonstrates organizational awareness (synthesizes culture, climate, norms and practices to anticipate, navigate, mitigate, and respond to decisions and behaviors) (67% very important).
A narrative box for comments or edits was available after these items. The survey was closed after 2 rounds (Figure 1).
Fourteen physical therapists participated in the paper. Ten panelists completed both rounds. The Delphi panel consisted of physical therapists (9 female physical therapists and 5 male physical therapists) in the United States, with a highest degree earned as PhD (8), EdD/DSc or equivalent (2), Masters (2), Baccalaureate degree (1), and Clinical Doctorate in Physical Therapy (1). All panelists currently hold or have held titled leadership positions. Each panelist identified participation in formal leadership training, for example, the APTA Education Leadership Institute, Higher Education Leadership program for women, or the LAMP leadership program of HPA the Catalyst of the APTA. All the panelists have scholarly records (presentation or published research) in topics within the umbrella of leadership.
Over 2 rounds (Figure 1), consensus at the level of “very important” was reached for 37 of the 76 knowledge, skills, and behaviors for all physical therapists regardless of years from licensure (Table 1). Consensus was reached at the level of “somewhat important” for all physical therapists for only 1 item: risk management skills. There were 20 additional leadership competencies that the panelists reached consensus as “very important” for physical therapists at greater than 1 year postlicensure but were unable to reach consensus for new graduate physical therapists (Table 2). For new graduate physical therapists, 3 competencies were identified as “not important”: talent development, budgeting skills, and transforms. For physical therapists greater than 1 year postlicensure, these same 3 competencies did not reach consensus (Table 3). Panelists were unable to reach consensus at any level on 15 of the leadership competencies for either new graduate physical therapists or therapists at greater than 1 year postlicensure (Table 4).
After round 2, the panelists had achieved consensus on only 53.9% of the potential leadership competencies for new graduate physical therapists and 76.3% of the potential leadership competencies for physical therapists at greater than 1 year postlicensure. The panelists' narrative comments confirmed they would not be able to achieve further consensus of the remaining items after round 2 of the Delphi process. Thus, the authors ended the Delphi process after 2 rounds.
Fifteen of the 40 comments from the panelists (37.5%) related to the overlap among knowledge, skills, and behaviors of leadership and the need for indicate a “level” of attainment for each item. For example,
“There are levels for most of these characteristics. For example, I expect a “certain amount” of professional independence and assertiveness [from a new graduate], but not what is expected of an experienced therapist.”
Five comments (12.5%) related to context. For example,
“‘Inspires’ is a difficult concept for me. I have been answering [the survey] about how a PT would inspire colleagues and company leadership. However, if you were to think about it regarding patients then this should be a very important skill. In thinking back on this and other items, it might be good to distinguish who the skill or knowledge is necessary for.”
The purpose of this paper was to outline what leadership knowledge, skills, and behaviors of leadership are very important for new graduate physical therapists (1 year or less postlicensure) as point-of-care professionals. A secondary purpose was to identify what leadership knowledge, skills, and behaviors of leadership are very important for physical therapists at greater than 1 year postlicensure for point-of-care professionals. To the authors' knowledge, physical therapists have not explored leadership competencies for new graduate and more experienced physical therapists using a Delphi panel. Each panelist met the predetermined criteria as a content expert in leadership in health care. Despite these qualifications, the panelists reached consensus at any level of importance on only 50% (38/76) of the potential leadership competencies for all physical therapists regardless of years of licensure (Tables 1 and 3) The panelists were unable to arrive at any level of consensus regardless of years of licensure for 18 competencies (Table 4).
Remarks from the panelists identified that they experienced challenges in gauging the importance of a competency due to the qualifier of “years postlicensure.” The category “greater than 1 year postlicensure” was felt to be too broad for some panelists. Comments also suggested the possibility some considered that the competencies may require sequential development or a linear progression of leadership knowledge, skills, and behaviors as physical therapists proceed across their career. The competencies that reached consensus as “very important” for all physical therapists regardless of years from licensure may be a set of foundational leadership competencies for entry-level physical therapists, while those for which consensus was reached as “not important” for entry-level physical therapists may be more appropriate for the experienced physical therapists within a professional development model.
The panelists reached consensus on “very important” leadership competencies for physical therapists greater than 1 year postlicensure; yet, they were unable to reach consensus for these same competencies for new graduate physical therapists (1 year or less postlicensure) (Table 2). This suggests disagreement among the panelists regarding expectations of new graduate physical therapists when considering leadership knowledge, skills, and behaviors. This finding may be symptomatic of the gap between academicians and those physical therapists in clinical practice within the profession. First, the panelists who participated in this paper were from clinical and academic settings. Those from the clinical setting may have a greater sense of urgency for the need to develop leadership competencies in new graduate point-of-care professionals than academicians. Second, academicians have only been expected to address leadership broadly in curricula as demonstrated by the CAPTE inclusion of 1 element related to leadership in the 2016 accreditation standards.35 The development of curriculum content to address this element may not yet be fully designed. The ABPTRFE core competencies37 of a resident have only recently been published and may not be fully indoctrinated into the expectations of a new graduate (less than 1 year postlicensure) who may be entering into an accredited residency. The authors believe that continued dialog on leadership competencies is essential to develop consensus on how physical therapists conceptualize leadership and to develop a standardized framework for preparation of the entry-level graduate and professional development of the more experienced point-of-care professional.
Four primary competency resources25,26,30,42 were used to develop the document sent to the panelists. In 2014, the APTA published a “leadership core competency” diagram43 and resource list to guide professional development of licensed physical therapists and physical therapist assistants. As a practical framework, the diagram and subsequent narrative lacks context and specificity to base the development of measurable leadership competencies across the career. For this reason, the survey to the panelists in this paper did not explicitly depict the APTA leadership core competencies, but rather, the terminology was confirmed to exist in 1 or more of the competency resources. Interestingly, none of the competencies where consensus was reached by the panelists were from 1 resource exclusively nor was 1 resource captured in its entirety. This suggests that disagreement among the panelists exists on how well these established competency resources meet the needs of physical therapists. Given these caveats, the authors caution against quick adoption of competencies where consensus was obtained in this paper. Further discussion is required to determine whether these competencies are comprehensive and address the scope of competencies needed of physical therapists from an entry-level curriculum and ultimately in practice perspective.
The authors suggest that physical therapists continue to explore options to consolidate, adapt, or adopt an existing evidence-based competency model of leadership development rather than develop one unique to the physical therapy profession. There may be benefits associated with the profession adopting an existing model that addresses leadership competencies across multiple professions. Discussions surrounding adoption of 1 or more of these established competency resources, rather than development of a physical therapy–specific competency framework, may result in better interprofessional communication that will ultimately result in leadership competencies recognized as necessary across disciplines. Common leadership competencies across disciplines may facilitate the improvement of teamwork, improved patient outcomes, and lower costs.
The authors of this paper were surprised by several findings. As an example, the competency cited as “transform” was determined by the panelists to be “not important” for new graduate physical therapist, and consensus was not reached for this competency for physical therapists greater than 1 year postlicensure. Given the APTA's vision of “transforming society by optimizing movement to improve the human experience”, the authors anticipated that this competency would have reached consensus as being “very important” for all physical therapists regardless of experience. This finding may be another example of the panelists' consideration of this competency for more experienced professionals. Further exploration of the panelists' perceptions regarding findings like this one that surprised the authors will need to be conducted through additional research on this topic.
The authors participated in extensive discussion, both electronically and in person, to collate the potential leadership competencies into the document sent to the Delphi panelists. This process was invaluable in understanding the full breadth and depth of knowledge, skills, and behaviors that relate to leadership and the authors' development of consensus. Although feedback from the Delphi panelists on the leadership competencies was shared between rounds 1 and 2, the process was conducted electronically. The lack of face-to-face discussion by the Delphi panelists may have hindered the full exchange of opinions and perceptions thus impeding the ability to reach consensus on some of the leadership competencies.
The panelists had diverse backgrounds, and experiences yet met all inclusion criteria that confirmed their recognition as experts in leadership. This diversity may have produced greater divergence on the perspectives of these leadership competencies.46 The authors were intentional to not prebias the panelists with a definition of leadership, and it is possible that without providing a standardized definition, the variety of perceptions and definitions of leadership held by the panelists may have further contributed to the inability to reach consensus on the remaining competencies.
Finally, although the number of panelists for the Delphi method is not prescribed44 the panel in this paper that consisted of 14 members of which 10 completed both rounds may be considered by some as small.45 Despite this perception, the authors are confident in the criterion-based method of selecting the panelists as representative of content experts on the topic of leadership in health care. Thus, a larger sample would not have resulted in significant differences to the findings of this paper but rather further illustrate disparity of perceptions on leadership and leadership competencies in the physical therapy profession at this time.
Leadership development is a hot topic in health care across all professions. Each discipline is at a different point and has differing perspectives on why and how leadership development should be incorporated as essential knowledge, skills, and behaviors within curricula and practice. The concept of leadership competencies, the resources available from internal and external to health care literature, and the early conversations on competency-based education are interdependent for both academic faculty and those in clinical practice. The leadership competencies from this paper that reached consensus as “very important” for all physical therapists provide a foundational set of competencies for continued discussions on curriculum design around leadership development to effectively prepare for the DPT role as point-of-care professionals. Ultimately, standardization of the definition of leadership and leadership competencies expected of physical therapists will provide opportunities for graduates to advance and actively participate in the transformation of health care that ultimately impacts the overall patient experience.
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