Healthcare Management and Leadership Roles

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nt. J. Electronic Healthcare, Vol. 12, No. 2, 2022 151
Copyright © 2022 Inderscience Enterprises Ltd.
Healthcare management and leadership roles
Renato Lopes da Costa*
BRU-Business Research Unit,
ISCTE – Instituto Universitário de Lisboa,
Lisbon, Portugal
Email: Renato.lopes.costa@iscte-iul.pt
*Corresponding author
Leandro Pereira
BRU-Business Research Unit,
ISCTE – Instituto Universitário de Lisboa,
WINNING LAB,
Lisbon, Portugal
Email: leandro.pereira@iscte-iul.pt
Rui Gonçalves
LABest – Instituto Piaget de Almada, Avenida Jorge Peixinho,
No. 30 – Quinta da Arreinela, 2805-059 Almada, Portugal
Email: ruiahgoncalves@gmail.com
Álvaro Dias
Universidade Lusófona de Humanidades e Tecnologias,
ISCTE – Instituto Universitário de Lisboa,
Lisbon, Portugal
Email: alvaro.dias1@gmail.com
Carlos H. Jerónimo
WINNING LAB,
Alameda das Linhas de Torres 152 Escritório 14,
1750-149 Lisboa, Portugal
Email: Carlos.Jeronimo@winning.pt
Natália Teixeira
ISG – Instituto Superior de Gestão,
Av. Mal. Craveiro Lopes 2A, 1700-284, Lisboa, Portugal
Email: Natalia.teixeira@isg.pt

152 R. Lopes da Costa et al.
Abstract: Within the changes in healthcare system across the years, new
challenges emerge for healthcare practitioners, organisations, and their
management boards, so the recognition of the need for different health
professionals in healthcare management has been growing. However,
physiotherapists’ core responsibilities remain rooted on therapeutic practices
and rehabilitation, developed primarily in clinical and hospital environments.
Regarding this scenario, physiotherapists’ functions continue to be absent to the
highest healthcare management and leadership positions, despite their
knowledge and understanding about how to ensure the best services to the
patients. As such, this research aimed to deepen the barriers to
physiotherapists’ involvement in healthcare management and leadership roles.
For such, a cross-sectional survey was performed with 287 physiotherapists,
carrying out quantitative and qualitative data collection. Findings suggest that a
lack of training and existent policies and laws are evident barriers to the access
of both healthcare management and leadership positions.
Keywords: business administration; healthcare management; leadership;
physiotherapy; management.
Reference to this paper should be made as follows: Lopes da Costa, R.,
Pereira, L., Gonçalves, R., Dias, Á., Jerónimo, C. and Teixeira, N. (2022)
‘Healthcare management and leadership roles’, Int. J. Electronic Healthcare,
Vol. 12, No. 2, pp.151–169.
Biographical notes: Renato Lopes da Costa holds a PhD in General
Management, Strategy and Business Development by ISCTE (Portugal) and
has articles published in several specialised journals in the East, the USA,
Canada, Africa, South America and Portugal. He is currently a researcher and
member of BRU-UNIDE and Professor at INDEG where he holds the post of
Director of the Master in Business Administration (MScBA) and guides
students in the development of Masters and PhD theses. He teaches business
strategy modules in executive and post-graduate master’s degrees. Since 2013,
he has also accumulated teaching duties as an Invited Professor at the Military
Academy where he teaches the knowledge management.
Leandro Pereira is a Professor of Strategy and Management at the ISCTE
Business School. He holds a PhD in Project Management. He is also the CEO
and Founder of WINNING Scientific Management. He is also the former
President of Business Case Institute, PMI Portugal Chapter and Training
Specialist of the Court of Auditors. As the CEO, he received from Best Teams
Leaders the award of Best Team Leader and CEO of Portugal in 2017 in
Portugal. He is also PMP from PMI and ROI certified. As a researcher, he has
published more than 80 scientific publications and ten books. As a student, he
received the Best Student Award from University of Minho. He is an
international expert in strategic management, project management, benefits
realisation management, and problem solving.
Rui Gonçalves holds a PhD in Management from the Lisbon School of
Economics and Management, with research in information systems for
operational risk management, Master’s in Statistics and Information
Management from the NOVA Information Management School, with research
in intelligent agents and graduated in Management by the Universidade
Internacional. In the academic area, he is a Full Professor at the Instituto Piaget
and an Invited Assistant Professor at ISCTE, NOVA IMS and ESCS.
Professionally, he regularly collaborates with different consultant firms in the
areas of management consulting and analytical models applied to decision
making. Previously, he coordinated the business analytics, operational risk,
compliance, fraud, audit and money laundering areas at SAS Portugal.

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ealthcare management and leadership roles 153
Álvaro Dias is a Professor of Strategy at the Instituto Superior de Gestão and
ISCTE-IUL, both in Lisbon, Portugal. He obtained his PhD in Management
from the Universidad de Extremadura, Spain, after an MBA in International
Business. He has over 24 years of teaching experience. He has had several
visiting positions in different countries and institutions including Brazil,
Angola, Spain, Poland and Finland. He regularly teaches in English,
Portuguese, and Spanish at undergraduate, master and doctorate levels, as well
as in executive programs. He has produced extensive research in the field of
tourism and management, including books, book chapters, papers in scientific
journals and conference proceedings, case studies, and working papers.
Carlos H. Jerónimo is a Portuguese Professor of Strategic Management and
Project Management at the ISCTE in Lisbon. His research covers a wide range
of areas: portfolio management, organisational behaviour, public sector
modernisation, and citizen driven theories. However, he is best known in
academia and requested by several European companies in the contribution of
the evolution and reinvention of business models. He has a degree in Computer
Science and Telematics from the University de Aveiro and a PhD in Business
Administration and Management from the ISCTE, a founding partner of
Winning Scientific Management, he has divided his career between
management consulting and academia. He is a mentor, and a guest speaker in
several management events. He was also the Vice President of PMI Portugal
from 2015 to 2018.
Natália Teixeira is an Associated Professor at the Instituto Superior de Gestão.
She has a PhD in Economics (University of Manchester, 1999), Master’s in
Economics (University of Manchester, 1995) and an undergraduation in
Economics (Universidade Nova de Lisboa, 1993). Her research interests are
economic growth and economics cycles, social responsibility and
environmental sustainability.
1 Introduction
Healthcare organisations play an important role in answer to communities’ demands and
have been developed a hybrid identity that results from the combination of two seemingly
incompatible characteristics – business orientation versus community care orientation
(Haigh et al., 2015). This places even more pressure on this kind of firms that are usually
managed by a wide range of stakeholders, where markets, professional, corporate, and
state co-exist and shape their dynamics and professions (Nunes and Martins, 2018).
In this sense, some authors defend the decentralisation and regionalisation of the
healthcare management systems, expecting improvements in financial impacts and
patients’ empowerment, as well as the development of health education and literacy. For
such, Velha and Lobo (2020) propose the promotion of health professionals as agents of
change and improvement, who would start to play new roles, like management, assuming
an enhanced role in the organisation and administration of their health services.
Considering physiotherapists, which belong to the third bigger health profession in
Europe (APFISIO, 2020), their role in healthcare management and leadership positions
remains fogged. There is also a lack of literature regarding physiotherapy involvement in
these two areas, and most of the investigations made so far were related to the Nursing

154 R. Lopes da Costa et al.
profession, from which some references were inferred to this study due to the similarities
between these two health professions.
Thereby, this study aimed to better understand what the barriers to physiotherapists’
involvement in healthcare management and leadership roles are, in Portugal, having the
following objective and research questions:
Table 1 Objectives and research questions
Objective Research questions
To identify and understand the
main barriers to the involvement of
physiotherapists in healthcare
management and leadership roles.
What are the barriers to physiotherapists’ appointment
and involvement in healthcare management?
What are the barriers to physiotherapists’ engagement
and acknowledgment in leadership?
Source: Authors’ elaboration
Despite this introduction, where the investigation theme is presented and justified, this
paper has four more sections, being them: the literature review, representing the
bibliographic research and information treatment; methodology, where all steps taken to
perform data collection and analysis are described; result’s presentation and discussion,
so data analysis is presented and discussion of the results is done, confronting the data
presented in the statistical outputs resulting from quantitative data collection and the
information reproduced in audio from the qualitative data collection with previous
studies; and finally the investigation’s conclusions.
2 Literature review
2.1 Physiotherapy and healthcare organisations
Physiotherapy, also called physical therapy, is the third-largest healthcare profession in
Europe and the most representative one in the rehabilitation field (APFISIO, 2020), being
defined as a specialist profession in the movement system and its relationship with
functionality, quality of life, and well-being. It develops activities for the promotion,
improvement, maintenance or restoration of mobility, functional autonomy, and the
health of people and communities, working both with healthy populations and
populations with different health conditions, including end-of-life conditions (APFISIO,
2020).
It is admitted that the use of hands, with or without the addition of any adjuvant
substance, with the aim of healing, is probably older than any other healing tradition, and
the origin of physiotherapy goes back to the beginnings of civilisation, when man used,
empirically, exposure to the sun, thermal waters, and massage, to relieve or cure his
ailments (Lucena, 2011). However, the start of the profession was mainly boosted by the
First and Second World Wars and the need to rehabilitate the injured soldiers, requiring
physiotherapists’ attention because of wounds, amputations, burns, cold injuries,
fractures, and nerve and spinal cord injuries (Shaik and Shemjaz, 2014).
In Portugal, physiotherapy has grown exponentially in the last 50 years, where there
are 12.891 physiotherapists and, every year, an average of 700 physiotherapists finish
their degrees and get into the job market. According to the physiotherapists’
competencies profile, these professionals are expected to evidence eight main skills:

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clinical, communication, management, collaboration, continuous professional
development promotion, professionalism promotion, scholar, and leadership (APFISIO,
2020). However, physiotherapists remain focused on clinical practice even though they
have a huge potential to add value in other healthcare fields.
Nevertheless, healthcare systems are heterogeneous and dynamic, where it is
necessary to provide leadership, direction, and coordination across all fields.
Professionals who work in healthcare services constantly seek to make the difference in
the lives of people they care about, which makes this work context significantly
rewarding and personally satisfying (Buchbinder and Shanks, 2017). As such, health
systems need to be managed in all its uniqueness to ensure not only the best services but
also the maximum profit, although this is often overlooked.
Healthcare services, whether they are public or private, include the same paramount
characteristics of any company: offering products and services, managing both human
and material/physical resources as well as facilities, strategically plan and coordinate
their tasks and, in the end, they intend not only to serve communities but also to generate
profit. As such, it is true to say that healthcare organisations develop a hybrid identity
that results from the combination of two seemingly incompatible characteristics –
business orientation versus community care orientation (Haigh et al., 2015; Nunes and
Martins, 2018).
This hybrid component makes hospitals and other health-related institutions to be
expected to provide both high-quality services and adopt efficient management practices,
so the absence of one of these expectations compromises the whole company (Nunes and
Martins, 2018), which could be reflected on its profit. Increased life expectancy, aging
population, and higher demand from certain conditions acquiring a chronic status and
greater need for care, results in bigger health expenditure and places higher pressure on
healthcare organisations (International Health Cooperative Organisation, 2018). As a
solution, their strategy should start to have into account, not only the money value, but
also the value that these institutions give to its employees, customers, suppliers,
environment, and communities, which creates value for society (Edmans, 2020).
2.2 Physiotherapists’ involvement in healthcare management and leadership
In this sense, the involvement of physiotherapists in tasks-related to healthcare
management and leadership would be of added value for health services, given the
proximity of these professionals to patients of the most varied conditions and their
extensive knowledge about the public and private sectors. “At the organizational level,
there was a perception that more diverse leadership resulted in better decision-making
and improved outcomes for health services” (Bismark et al., 2015). However, there is a
lack of investigation about Physiotherapy and its place in healthcare management and
leadership, worldwide. Some research has been done related to Nursing and, considering
the nature and proximity between these two professions, some insights can be taken from
their studies.
In 2011, Khoury et al. performed a survey to examine how Nursing was viewed by
decision makers and opinion leaders and findings identified principal barriers to nurses
having more influence and exerting more leadership: 69% of respondents said physicians
are the key decision-makers, and 68% said physicians, not nurses, are revenue generators.
Participants also considered nurses are not prepared to undertake and succeed in

156 R. Lopes da Costa et al.
leadership positions due to a lack of formal management training and that excessive
workload reserve little time for nurses to dedicate to leadership roles (Khoury et al.,
2011).
Years later, Prybil (2016) analysed eight independent studies to better understand
how Nursing engagement in governing healthcare organisations has been evolving;
realising nurses’ involvement in governance continues to be modest and uneven.
According to the author, key reasons that have contributed to this situation are gender
disparities, uneven understanding and appreciation of the Nursing profession, and board
policies on eligibility for board appointments. “The result is these boards do not benefit
fully from the rich experience, input, and insights that highly qualified and dedicated
nurse leaders can bring to governance deliberations and decision making” [Prybil, (2016),
p.4]. Still regarding gender disparities, also Sundean and McGrath (2016) and Murt et al.
(2019) identified gender bias as a barrier for board diversity inclusive for nurses and
women.
Sundean et al. (2017) carried out a study that supported nurses for board leadership.
Their findings suggested nurses should be appointed to boards’ direction based on their
valuable knowledge (about patients, health needs, healthcare organisations, and
evidence-based practice), skills (including patient advocacy, team building,
problem-solving, communication, leadership, innovative thinking, and change agency),
perspectives (holistic patient care), and benefits and opportunities (to influence health
policy, trust and confidence from patients, and opportunity to role model governance
leadership and decision-making), which perfectly matches physiotherapists, their
functions, and their added value.
However, concerning to boards policies, in a document published in Portugal, in
2010, that remains valid nowadays, the Ministry of Health defends the need for the
creation of an intermediate and peripheral management structure, with functional content
and real autonomy, central to an effective decentralisation of management modalities, to
delegate responsibilities where service quality and processing are established (Fernandes
et al., 2010). This structure, called ‘hospital board of directors’ is mandatorily managed
by a physician, a nurse, and a manager, all pointed by the board of directors, and no other
health practitioner is expected to be part of these boards, which could be flagged as a
barrier to healthcare management involvement.
Regarding leadership, the Chartered Society of Physiotherapy (Thornton, 2016)
investigated the current thinking on this matter within the Physiotherapy profession due
to the transformational changes desired to meet the increasing demand for quality
services. The study concluded that traditional structures and roles are barriers for
physiotherapists to move into leadership positions and, also, that remains a medical
dominance in clinical leadership, where fewer female physiotherapists are taking up these
roles. As such, the CSP warns of the need for more physiotherapists to apply for
leadership in healthcare systems and for the lack of evidence regarding leadership in
physiotherapy practice.
McGowan and Stokes (2015) analysed several studies and discussion papers
regarding leadership in physiotherapy and healthcare to summarise the main factors
concerning clinical leadership, leadership characteristics, main barriers and styles, and
other issues about this topic. They found that barriers included staff shortages, trends
towards physicians, fiscal constraints, and organisational structures that preclude health
practitioners’ decision making. Another possible barrier pointed out by the authors was
gender bias, once physiotherapy has a predominance of female professionals. Yet, and

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not least important identified factor, was influence setting, that means, the context in
which setting occurs could influence leadership involvement from physiotherapists.
In Nursing, a descriptive cross-sectional survey aimed to examine nursing leadership
roles, goals, and barriers (Peltzer et al., 2015). Participants identified as main barriers to
becoming a leader insufficient time during work, insufficient time available outside of
work, and perceived need for further leadership development before serving as a leader.
Also, needing additional education and/or training, which was too stated by Alhassan
et al. (2020) in its findings, and limited organisational leadership opportunities. Despite
these perceptions, some nurses also reported they were not interested in a leadership
position, or that they had already achieved leadership goals (Peltzer et al., 2015). These
barriers deserve to be addressed in physiotherapy leadership framework, in further
researches.
Also, Horstmann and Remdisch (2019) performed a survey regarding drivers and
barriers that are influencing factors in the successful practice of health-specific leadership
in healthcare facilities, in Germany. Findings revealed creativity, innovative, and
proactive capacities, as well as exchange with external networks, willingness to take
risks, and critical self-reflection, individual leader’s enablers to succeed. At the
organisational level, the existence of a supportive head of management was precepted as
a facilitator, once it often hints more financial, personal, and time resources, flexibility,
and a bigger scope of action for the remaining managers. The lack of these resources,
task requirements, and legal frameworks were mentioned as barriers to leadership
(Horstmann and Remdisch, 2019).
As a matter of fact, McGowan et al. (2019) explored female healthcare students’
perceptions and experiences of leadership in healthcare throughout a focus group. Gender
differences were pinpointed as a barrier once students considered to be a difference in the
experiences of male and female healthcare professionals, including parental
responsibilities, maternity and paternity leave, and gender stereotypes. The authors also
found a reluctance to demonstrate leadership and lack of interest to take on this role.
During this bibliographic research, it was also found a 2012 study, from Hassmiller
and Combes (2012), that hypothesised nurses as having a large focus on their profession
and, consequently, on patients care as a barrier to their recognition as leaders. Regarding
physiotherapists, in Portugal, these practitioners also have a big concern in patients’
rehabilitation which acknowledges future research on this matter, despite only one
investigation were found to address it.
In this sense, some questions remain to better understand why other professionals,
like physiotherapists, are not considered to have the same opportunities to constitute
these boards and participate in healthcare management and leadership. The involvement
of these practitioners on governing bodies may be an asset to healthcare organisations
because of their deep knowledge of clinical problems, best practices, quality indicators,
and other subjects related to the safety and quality of care (Mason et al., 2012).
A lot of research still needs to be done regarding physiotherapy and its role in
healthcare management and leadership roles, in order to keep up to better understand the
existing asymmetries and divergences, so changes in healthcare systems and communities
demand could be answered accordingly.

158 R. Lopes da Costa et al.
3 Methodology
The aim of this study is to know and deepen what are the barriers to the involvement of
physiotherapists in healthcare management and leadership roles, in Portugal. For this, a
cross-sectional survey was performed using a convergent mixed-method approach,
combining both quantitative and qualitative methods, through primary information
sources, collected roughly at the same time to answer research questions (Creswell, 2014;
Kothari, 2004; Shorten and Smith, 2017). This methodology enables to seek a more
comprehensive and complete viewpoint of the research landscape, viewing research from
different perspectives and through diverse lenses (Shorten and Smith, 2017).
Also, the present investigation was based on a pragmatic or inductive character, once
it is not intended to reach true conclusions from equally true premises (deductive
method), but only by means of induction to measure a set of social phenomena under
study, in order to find a set of probabilities that allow to establish comparisons and
discover relationships between them (Carmo and Ferreira, 1998). Overall, four main steps
were carried:
1 bibliographic research and information treatment
2 transfer of the theoretical construct to the instruments developed by the authors
3 both quantitative and qualitative data collection
4 data analysis presentation and discussion of the results. Figure 1 illustrates the
research model used.
Figure 1 Methodological model design
Source: Authors’ elaboration

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ealthcare management and leadership roles 159
Regarding quantitative data collection, the purpose was to produce a database from which
characteristics and relationships were inferred to the population being studied (Kothari,
2004), thereby resorting to statistical and inferential analysis. For such, a structured
online questionnaire composed of closed questions was developed in Portuguese by the
author, considering the Literature Review and Objectives that state the investigation. The
instrument was pretested by four physiotherapists to ensure construct validity and small
changes were made regarding their feedback. Also, a Cronbach’s alpha of 0.55 was
obtained, which means that the factors under study are directly related to each other in a
medium/good way.
After, all 19 Portuguese physiotherapy colleges and the Portuguese Association of
Physiotherapists were contacted both by call and e-mail with the aim of disseminating the
questionnaire to its former students and members. On balance, the instrument had 22
multiple-choice items on a Likert scale, scored from 1 to 5 (1 – totally disagree;
2 – disagree; 3 – neither agree, nor disagree; 4 – agree; 5 – totally agree), and one final
item to rank competencies in order of importance. In the end, an anonymous
socio-demographic data form was requested to fill so that sample could be characterised,
and relationships could be established between the results. Results were imported via
Excel into the IBM® SPSS® Statistics Software (version 27), proceeding to the analysis
and consequent elaboration of quantitative results through the necessary outputs, using
descriptive statistics for inferring conclusions.
Regarding qualitative data collection, a semi-structured interview guide was prepared,
taking into account the Literature Review, and personal interviews were carried out, once
this method was considered to be the most adequate to collect the elements of analysis, so
supplementary information could be collected and the interviewer could organise,
control, and deepen the various thematic areas, which is often of great value in
interpreting results (Flick, 2009; Kothari, 2004).
In terms of the qualitative analysis technique used to interpret the data reproduced in
the interviews, it was used content analysis, via MAXQDA software. It was related the
semantic structures (signifiers) with the sociological structures (meanings) of the
statements, in order to articulate the surface of the texts with the factors that determine
their characteristics (Duriau et al., 2007). This had as main objective to complement the
results obtained in the quantitative part of this investigation and to deepen the phenomena
under study, being this a pioneering exploratory work in the proposed areas.
From the voice reproductions, the process of explanation, systematisation and
expression of the content of the messages, promoted by the content analysis, was
organised in accordance with the three chronological poles of Bardin (1977), that is, in a
first stance, giving way to organisation and systematisation of ideas, in a second one, all
the material was explored, and in the end, the treatment and the respective interpretations
of the results obtained were carried out. Figure 2 shows the categorisation and
codification of the interview corpus that originated the qualitative analysis.
Qualitative approach was conducted during July 2020, from a non-probabilistic
sample for convenience, intentionally selected, where the participants were from both
private and public contexts of clinical practice and across different geographic locations
covering in an enriching way the subjects under investigation. Quantitative data was, as
well, collected from a convenience sample, taking place between July and August 2020.
Overall, 290 answers to the questionnaire were obtained, from which three were excluded

160 R. Lopes da Costa et al.
once they did not meet inclusion criteria, and nine physiotherapists were interviewed.
Table 2 synthesises the methodologies used to answer each research question.
Figure 2 Categorisation and codification of the interview corpus for qualitative analysis
Source: Authors’ elaboration
Table 2 Methodology used for research questions
Objectives Research questions Methodology Literature review
OBJ 1 – to
identify and
understand the
main barriers to
the involvement
of
physiotherapists
in healthcare
management
and leadership
roles.
(Q1). What are the
barriers to
physiotherapists’
appointment and
involvement in
healthcare management?
Descriptive
statistics and
content
analysis
Alhassan et al. (2020), Murt
et al. (2019), Prybil (2016) and
Sundean and McGrath (2016)
(Q2). What are the
barriers to
physiotherapists’
engagement and
acknowledgment in
leadership?
Descriptive
statistics and
content
analysis
Bismark et al. (2015),
Horstmann and Remdisch
(2019), McGowan and Stokes
(2015), McGowan and Stokes
(2019), Peltzer et al. (2015) and
Thornton (2016)
Source: Authors’ elaboration
4 Results analysis
The quantitative sample is composed of 287 physiotherapists working in Portugal, from
which 224 are women (78%) and 63 are men (22%). The average sample’s age is 33
years old (s.d. 10 y.o.), with ten years of professional experience (s.d. 10 y.o.), and the
majority has a bachelor’s degree in Physiotherapy (58.9%). For the qualitative sample,
nine physiotherapists were interviewed, from which five had a bachelor’s degree
(55.6%), and 4 had a Masters (44.4%), one of which was completing a PhD. This sample
was constituted by 66.7% of female participants, which ages were ranged between 24 and
61 years old.

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ealthcare management and leadership roles 161
4.1 Barriers to physiotherapists’ appointment and involvement in healthcare
management
This first research question aimed to understand the main factors that difficult
physiotherapists’ access to management roles. Regarding questionnaire results, majority
of the participants considered that:
1 physiotherapist did not have the necessary knowledge of healthcare management
when they finish the degree
2 the current Portuguese NHS structure does not allow them to get into management
roles
3 there is a lack of recognition of the Physiotherapy profession
4 there is an excessive workload that does not let them focus on management
5 there is a prevalence of other health professions on these roles. Table 3 shows
sample’s answers and respective percentages.
Table 3 Barriers to healthcare management quantitative results
Question Likert scale 1–5
1 2 3 4 5
1 20.6% 38.7% 17.8% 19.9% 3.1%
3 39.7% 39.7% 16.4% 3.1% 1.0%
4 0.3% 4.5% 4.5% 38.0% 52.6%
5 18.8% 28.2% 30.3% 18.1% 4.5%
7 7.0% 9.4% 17.1% 36.2% 30.3%
8 21.6% 41.1% 22.3% 11.8% 3.1%
9 1.0% 1.7% 4.2% 34.5% 58.5%
Source: Authors’ elaboration
One last question appeared on the instrument asking for participants to rank the eight
competencies of the physiotherapists’ profile in order of importance. It aimed to
understand in which degree sample would classify management skills on their daily
practice. Descriptive statistics revealed that Management appears in second to last place,
in order of importance, followed only by leadership, the last of the rank. This suggests
that Portuguese physiotherapists remain really focused on clinical practice and seem to
forget management and leadership as relevant skills and means to develop their
profession.
Regarding qualitative results, these are mostly aligned with the questionnaire answers
and results are aggregated on Table 4. Participants considered lack of management skills,
existent laws and policies, lack of interest, other health-related professions domain, and
lack of time as the main barriers to physiotherapist’s engagement on healthcare
management.
However, other themes emerged from the interviews. Five out of nine participants
mentioned that salary compensation was absent or insignificant when physiotherapists
assumed healthcare management roles, which can lead to a lack of interest. Although, this
assumption does not match the questionnaire findings where most of the physiotherapists

162 R. Lopes da Costa et al.
answered to be interested on this role. Still, three participants referred that there is a lack
of stimulation during the degree for management importance and where there is no boost,
there is no space for interest, and, regarding other health-related professions’ dominance
in this field, physicians and nurses were the only ones mentioned.
Table 4 Barriers to healthcare management qualitative results
Text Generic category Sub category Frequency Interviewee
Lack of management training and
skills during the degree.
1.1. 1.1.1. 8 1, 2, 3, 4,
5, 6, 7, 8
There are policies and laws that
bar physiotherapist’s involvement
in management.
1.1. 1.1.1. 8 1, 2, 3, 4,
5, 6, 7, 8
Lack of interest and initiative
from physiotherapists.
1.1. 1.1.1. 6 3, 5, 6, 7,
8, 9
The salary for physiotherapists in
management roles is the same.
1.1. 1.1.1. 5 1, 3, 5, 7, 9
There are other health
professionals’ domains on
management roles – physicians
and nurses.
1.1. 1.1.1. 5 2, 3, 5, 8, 9
Physiotherapy uneven
understanding and recognising,
sometimes due to a lack of health
literacy.
1.1. 1.1.1. 4 5, 7, 8, 9
There is lack of time to manage,
due to excessive workload, which
compromises management
quality.
1.1. 1.1.1. 4 1, 4, 7, 9
Traditional focus on clinical
practice takes a little bit away the
purpose that the physiotherapist
could coordinate.
1.1. 1.1.1. 3 6, 7, 8
Our profession is very
commodious.
1.1. 1.1.1. 2 6, 7
Lack of human resources leads to
a lack of time to manage.
1.1. 1.1.1. 2 1, 9
Lack of organisation and guidance
of the profession.
1.1. 1.1.1. 2 1, 8
Healthcare management subjects
during graduation are not taught
at the right timing for students to
understand their importance.
1.1. 1.1.1. 1 6
Source: Authors’ elaboration
Thus, it is possible to conclude, through the questionnaire and the interviews, that there is
unanimity regarding lack of management training and skills in taking on these roles, like
Khoury et al. (2011), Sundean and McGrath (2016), and APFISIO (2020) stated in their
findings. Literature also meets the results of this investigation regarding existent laws and
policies as barriers to physiotherapists involvement on management (Prybil, 2016),
physicians domain on healthcare management (Khoury et al., 2011), uneven

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ealthcare management and leadership roles 163
understanding of the profession (Prybil, 2016), and little time for physiotherapists to
dedicate to management (Khoury et al., 2011).
However, in what concerns to gender disparities, suggested by Murt et al. (2019),
Prybil (2016), Sundean et al. (2017), and Sundean and McGrath (2016), both samples of
this study do not consider gender to be a barrier to physiotherapist’s appointment to
healthcare management positions. The quantitative sample classified the topic with 3/5
(‘neither agrees, neither disagrees’), and interviewees reinforced that gender is not a
limitation: “Of what I have seen, not really. No, I don’t realize. (…) My clinic is headed
by women, physiotherapists, three, so ... I don’t see much [barriers]” (Interviewee 5).
In this same reasoning, from this study, it is not possible to take clear conclusions
regarding physiotherapists’ interest in assuming healthcare management positions. On
one hand, most of the quantitative sample revealed to have an interest in management
roles, but on the other, qualitative results suggest that there is no interest from
physiotherapists. As such, interviews’ findings are aligned with Khoury et al. (2011) and
Sundean and McGrath (2016) investigations’ results, however, the same are not true for
the questionnaire answers.
4.2 Barriers to physiotherapists’ appointment and involvement in leadership
Like the previous question, this topic aimed to understand the main barriers to
physiotherapists’ engagement and acknowledgment in leadership positions. For such,
participants completed a dedicated group of the questionnaire directed to leadership and
were asked to give their opinion during the interviews, considering their own
experiences. Tables 5 and 6 show both quantitative and qualitative results for this
question.
Table 5 Barriers to leadership quantitative results
Question Likert scale 1-5
1 2 3 4 5
13 7.3% 23.7% 25.1% 32.1% 11.8%
14 0.7% 4.2% 7.7% 49.1% 38.3%
16 19.5% 31.4% 26.1% 16.7% 6.3%
17 4.2% 15.0% 18.8% 41.8% 20.2%
18 0.0% 0.3% 3.8% 42.9% 53.0%
19 1.4% 7.3% 15.7% 46.7% 28.9%
21 3.8% 16.0% 17.1% 42.2% 20.9%
Source: Authors’ elaboration
Considering questionnaire answers, the main barriers identified were similar to the
healthcare management barriers findings. Results suggest that:
1 organisational structures, as well as
2 other health-related professions domain, were considered to be a barrier to these
professionals to lead, which was identified by McGowan and Stokes (2015) and
Thornton (2016) on their investigations. Also

164 R. Lopes da Costa et al.
3 lack of time for Leadership was considered a barrier by the participants, meeting
Horstmann and Remdisch (2019) and Peltzer et al. (2015) conclusions regarding this
theme
4 lack of preparatory training to lead was also noted, as previously observed in the
literature (McGowan et al., 2019; McGowan and Stokes, 2015; Peltzer et al., 2015).
Table 6 Barriers to leadership qualitative results
Text Generic
category
Sub
category Frequency Interviewee
Physiotherapists are not specifically trained
to be leaders.
1.1. 1.1.2. 6 1, 3, 4, 5,
6, 7
There are physicians and nurses’ domain on
big and multidisciplinary teams.
1.1. 1.1.2. 5 2, 5, 7, 8, 9
The existing structure does not allow
physiotherapists to take on leadership roles.
1.1. 1.1.2. 4 6, 7, 8, 9
Lack of interest and initiative by
physiotherapists.
1.1. 1.1.2. 4 3, 5, 6, 7
Human resources management could be a
barrier to lead.
1.1. 1.1.2. 3 1, 4, 8
Excess workload reserves no time for a
group meeting or for leadership.
1.1. 1.1.2. 3 4, 5, 7
Physiotherapists do not see the need for a
leader to be present on a team.
1.1. 1.1.2. 2 3, 5
Traditional focus on clinical practice takes a
little bit away the purpose that the
physiotherapist could lead.
1.1. 1.1.2. 1 6
Physiotherapy uneven understanding and
recognising, due to a lack of health literacy.
1.1. 1.1.2. 1 5
Physiotherapists forget to develop soft skills. 1.1. 1.1.2. 1 6
Source: Authors’ elaboration
Regarding physiotherapists focus on clinical practice that could call into question their
recognition as leaders, as Hassmiller and Combes (2012) stated in their study, there is no
consensus on this investigation, given the array of responses: 23.7% disagrees with the
statement, 25.1% neither agrees nor disagrees, and 32.1% agrees. During the interviews,
only one physiotherapist mentioned that factor, which makes this a topic to be further
explored.
Looking to the interviews’ results, most of the participants referred that
physiotherapists are not specifically trained to be leaders during their degrees, like
literature addresses (McGowan et al., 2019; McGowan and Stokes, 2015; Peltzer et al.,
2015), however, some defended the idea that leadership is a process and that it takes time
to be able to lead: “(…) are Leadership processes that are being built” (Interviewee 4).
Another mentioned barrier was physicians and nurses’ domain on leadership regarding
big multidisciplinary teams, which is in line with bibliography findings (Khoury et al.,
2011; Peltzer et al., 2015; Sundean and McGrath, 2016; McGowan and Stokes, 2019),
still, some participants highlighted that, in smaller teams, physiotherapist is a key piece to
interrelate the patient rehabilitation process and, thus, lead.

H
ealthcare management and leadership roles 165
Other qualitative findings that meet both literature and quantitative results are the
existing structures, that bar Leadership to physiotherapists, lack of time due to excessive
workload, and traditional focus on clinical practice that calls into question their
recognition as leaders – “that traditional idea that the physiotherapist ‘does’ (...)
sometimes takes away the purpose that the physiotherapist can lead” (Interviewee 6)
(Hassmiller and Combes, 2012; Horstmann and Remdisch, 2019; McGowan et al., 2016;
Thornton, 2016).
Nonetheless, like healthcare management barriers’ results, there is no consensus
regarding physiotherapists’ interest to lead, in this study. While most participants in the
questionnaire rated their response as having an interest in leading a working team, the
physiotherapists interviewed reported to feel a lack of interest and initiative in leading,
among the profession. “If I speak for myself (…) I am interested in this type of role (…).
But I see a lot of colleagues who disconnect a lot and who don’t even take a firm stand in
what they do, or in the environments in which they are inserted in (…)” (Interviewee 5).
As such, only qualitative results meet the literature findings (Khoury et al., 2011;
McGowan and Stokes, 2019; Peltzer et al., 2015; Sundean and McGrath, 2016).
Regarding gender disparities, the results of this investigation do not meet McGowan
et al. (2019), McGowan and Stokes (2015), and Thornton (2016) conclusions, as stated in
the literature review. Both quantitative and qualitative samples do not consider gender
bias as a barrier to physiotherapists be involved on leadership. “I never felt offended or
disowned by being a woman, no, no” (Interviewee 1).
Interestingly, new ideas appeared, regarding leadership. Three out of nine participants
stated that human resources management could be really challenging and sometimes a
barrier to leadership – “(…) the main problems in the processes of leadership, at this
moment, clearly it is, the management of resources that are people” (Interviewee 4).
Other professionals stated that physiotherapists do not see the need for a leader to be
present on a team, there is an uneven understanding and recognising of Physiotherapy,
and physiotherapists often forget to develop soft skills, so relevant to lead.
In the end, and in all interviews, there were differences between contexts of public
practice versus contexts of private practice. These asymmetries were widely mentioned
by the interviewees and it would be useful, in future investigations, to understand the
extent to which different contexts may have different influences on facilitators to
physiotherapist’s involvement on healthcare management and leadership, in Portugal.
5 Conclusions
The changes in health reality during the last years have increased pressure on healthcare
management and leadership, which makes it indispensable for organisations to rethink
their strategies and adapting them to the competitive environment in which they live
(Lopes da Costa and António, 2011). As such, some authors defend boards’ diversity
when it comes to involving healthcare practitioners in decision-making once it can
increase success and improve organisational outcomes, as well as leverage their valuable
expertise (Bismark et al., 2015; McBride, 2017; Sundean et al., 2017).
Hereupon, this investigation aimed to understand barriers to physiotherapists’
involvement in Healthcare management and leadership roles, in Portugal. Following an
extensive literature review on this objective, and after conducting nine interviews with

166 R. Lopes da Costa et al.
Portuguese physiotherapists and collecting 287 answers to a questionnaire, it was
possible to reach a set of pertinent conclusions about the proposed theme.
As evidenced in eight of the nine interviews carried out and also by most of the
questionnaire answers (59.3% of the respondents), the lack of skills and training at the
level of the degree is one of the barriers to physiotherapists’ involvement in health
management positions, having been, in many interviews, referred in the first place by the
participants as one of the main barriers when they were asked about the theme. This
finding is fully aligned with the literature review that states nurses have a lack of formal
training which limits their access to management roles (Alhassan et al., 2020; Murt et al.,
2019; Prybil, 2016; Sundean and McGrath, 2016). As mentioned before, most of the
studies that support this investigation were performed with nurses, due to a lack of
evidence regarding this topic in Physiotherapy.
Still on the barriers to healthcare management engagement, overall, participants
agreed that the current health structures do not allow physiotherapists to get into
Management roles (79.4% of the questionnaire respondents), which most of the times is
directly related to the existence of policies and laws that bar physiotherapists involvement
in these positions, as eight of the nine interviewees mentioned as barriers to this role
appointment. As such, from this investigation, it is possible to conclude that the current
Portuguese healthcare system design, as well as its policies and laws, is a barrier to
physiotherapists to participate in decision-making and management-related subjects,
which confirms Prybil (2016) findings.
Also, the lack of appreciation of the Physiotherapy profession was pointed out by
both samples as a barrier, like Prybil (2016) stated in his study with Nursing. In total,
90.6% of the physiotherapists that answered the questionnaire recognised it, and four in
nine interviewees mentioned this factor as barrier and some added that it could be due to
a lack of health literacy from the Portuguese society. More, other health-professions
domain was too considered to be a barrier to management by 93.0% of the questionnaire
participants, and five of the interviewees said that physicians and nurses are usually the
health-professionals that occupy these positions, as Khoury et al. (2011) mentioned in
their findings.
The excessive workload that physiotherapists usually have was pinpointed by 62.7%
of the quantitative sample, and four of the professionals interviewed, as a barrier to
physiotherapists involvement in healthcare management, as suggested by Khoury et al.
(2011) in his investigation. However, new potential barriers emerged from the interviews,
like salary compensation, that remains the same and the physiotherapist only accumulate
roles, traditional focus on clinical practice which takes away the idea that
physiotherapists are able to manage, professional accommodation, lack of human
resources and guidance of the profession, and also the timing in which
management-related subjects are taught during the degrees. These factors should be
addressed to future investigations, from now.
Still regarding barriers addressed on this study, but for leadership roles, conclusions
are quite similar. Participants consider that physiotherapists do not receive training for
leadership during the degree (62.0% of the questionnaire’s answers and six in nine
interviewees), and that there is other health-related professions domain in leadership roles
(95.9% of the quantitative sample and five interviewees), specially physicians and nurses.
They also agree on current structures as barriers to leadership access (87.4% of the
respondents and four interviewees have mentioned it).

H
ealthcare management and leadership roles 167
However, unlike healthcare management findings and the literature (Hassmiller and
Combes, 2012), it is not consensual between the participants of the quantitative sample if
the traditional focus on clinical practice is, or is not, a barrier to these professionals’
engagement in leadership roles, and only one interviewee has mentioned it. In the same
reasoning, both healthcare management and leadership barriers’ results do not reveal
agreement regarding physiotherapists’ interest to manage or lead, in this study.
While most participants in the questionnaire rated their response as having an interest
in managing a health unit or leading a working team, the physiotherapists interviewed
reported to feel a lack of interest and initiative, amongst the profession, like literature
suggests (McGowan and Stokes, 2019; Peltzer et al., 2015). As such, more investigations
regarding interest topics and clinical practice focus should be addressed. Regarding
gender disparities for physiotherapists’ involvement in healthcare management and
leadership roles, both samples did not recognise it as a barrier, unlike Murt et al. (2019)
findings.
Therefore, it was possible to answer to the two research questions proposed in the
beginning of this work as increase the contribution to Physiotherapy and Business
Administration fields. There were many agreements with the literature review, but also
some disagreements and, also important, new and uncovered barriers to explore in the
future. It is plausible to say that this investigation fully achieved its objective, being
pioneer in Portugal and a starting point to boost Healthcare Management and
Physiotherapy profession.
The potential for the involvement of health professionals who work directly with
communities is a topic that has been debated in recent years, given the benefits that come
from their professional experiences, as well as highly qualified and dedicated patient
inputs and insights that enrich the discussions and decision-making in health management
boards (Prybil, 2016). This, consequently, results in an increase in the institution’s value
to the community, and an optimisation in healthcare organisations’ profit (Velha and
Lobo, 2020; Edmans, 2020).
As such, this investigation is the first in Portugal and one of the few in the world that
explores the factors that influence access and involvement in healthcare management and
leadership from health professionals, namely physiotherapists. In this sense, these study
inputs are considered to be a strongly positive and significant contribution to the
Physiotherapy profession in Portugal, insofar as it makes known the perceptions of 287
Portuguese physiotherapists about the main difficulties and incentives that currently face
in the labour market.
Regarding business administration, this research reinforces before hospital managers
the pertinence and need to involve and appoint physiotherapists in health
decision-making, thus making them aware of the current factors perceived by the
professionals themselves that facilitate and inhibit the processes, in this theme. As such, it
is expected to raise awareness and optimise the health units in Portugal, both through the
quality of the services provided and the income generation, over a window of
opportunities for physiotherapists’ involvement in healthcare management and leadership
roles.
In short, this work is a pioneer within its theme and an important leveraging for the
Physiotherapy profession and the innovation of health services, in Portugal, making an
introductory contribution due to the lack of evidence. It should also be noted that the
labour reality in Portugal has its particularities, which may also explain the divergences

168 R. Lopes da Costa et al.
in the results comparing to the literature review. In this sense, it is also important to note
that it is essential to continue to carry out in-depth research that characterises and
analyses this topic in detail, in order to allow the identification of key factors that make it
possible to develop new strategies to improve health services.
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