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INTRODUCTION

According to the World Health Organization (WHO), countries around the world face challenges in capacity building in terms of human factors, within health systems [1]. In today's healthcare work environment, it is difficult for a healthcare professional of any specialty, to harmonize the care of patients or clients, their needs, together with a large number of factors related to the organization of work in rehabilitation institutions, where they are often exposed to stressful events and experiences. Challenges associated with physiotherapy practice include patients in extremely demanding psychophysical conditions but also frequent interpersonal conflicts due to the multidisciplinary nature of the rehabilitation process in which besides physiotherapists and patients participate. health professionals with whom they need to cooperate in order to achieve the ultimate goal, which is the effective treatment of the patient or client [2,3]. Therefore, leadership, administration, management and professionalism as skills, need to be integrated as an integral part of the theory and practice of physiotherapy. These four elements symbolize business functions [4]. Accordingly, the functions of leadership, administration, management and professionalism, are not independent of each other and are also related to the elements of the client-patient model and thus integrated into the physiotherapeutic practice [5].

LEADERSHIP

Today, leadership is increasingly recognized as a key component of organizational success. It is increasingly in the spotlight precisely because it is considered a key variable of organizational behavior. The clinical and general environment, which includes health care institutions, represents a specific challenge for leadership that arises from a combination of environmental and organizational factors [6]. These factors include: diverse regulatory influences, limited financial resources, multiple hierarchical systems, divisions between administrator and clinician roles, and different employee populations [6].
Recognizing the complex challenges and diversity of roles of leaders working in a health context have led to the development of the concept of clinical leadership. The term clinical leadership originated from the practice of nursing in which nurses found themselves in managerial roles, but has evolved to include everyone with a clinical background today [7]. Clinical leadership is most focused on providing effective health care "on the front lines" through evidence-based practices to improve patients' health outcomes [8]. Clinical managers are defined as “front-line” health workers who have retained a certain clinical role, but also have a significant stake in strategic direction, operational resource management and collaborative work activities where health professionals work together but retain their autonomy [9]. Storey and Holtie pointed out clinical leadership functions that include: maintaining levels of employee engagement, providing technical expertise in providing action plans that are feasible and useful from a patient perspective [10].
Leadership development is a current topic in health care among all health professions. Each discipline observes it from a different aspect and has a different view on how and why the development of leadership qualities should be included in the fund of basic knowledge, skills and behaviors both within educational curricula and in health practice.
Leaders are people who have the ability to lead others to achieve desired goals and increase productivity, create sustainable change and inspire others to pursue professional development [11-13]. One of the general definitions of leadership is that it is a process of influencing others to understand and agree on what needs to be done and how to do it, and the process of encouraging and directing individual and collective efforts to achieve common goals [14]. Leadership in health care includes influencing the activities of others that are aimed at achieving certain goals, dictating and harmonizing the speed and direction of change, as well as encouraging innovative practices [15]. Development in the field of leadership in terms of acquiring knowledge and skills, is the personal choice of the individual. People who have a desire to develop leadership skills may be those who believe they have good basic leadership characteristics, have had experience in leadership positions, or are in some way encouraged to seek leadership positions. The process of leadership development is a journey that involves a personal understanding of transformational leadership and the growth of leadership practice [16]. Research in the field of leadership has identified certain characteristics that are needed to cope with the challenges of leadership in complex systems, in a time of rapid change and expansion of knowledge in the health sector [17]. Three characteristics of leadership are mentioned that are consistently related to effective leadership in various fields of health care, namely: emotional intelligence, vision and business acuity [18]. Stanley identified seven clinical characteristics of leadership including clinical expertise, direct involvement in clinical activities, communication and interpersonal skills, modeling and motivating, implementing and improving high standards of health care, empowering others, and guiding oneself in recognized values [19]. Research in health care in general, to a significant extent, studies leadership as a means of achieving quality and efficiency in the provision of health care [20,6]. In their study, Desveaux and Verrier examined the attitudes of physiotherapists about leadership characteristics in physiotherapy practice and found that three key characteristics were identified, namely communication skills, professionalism and credibility [21]. The importance of leadership in the profession of physiotherapist has been recognized by professional organizations of physiotherapists [22]. wrote about the importance of leadership versus leaders, emphasizing the importance of the very concept of leadership that transcends and applies not only to the formal roles of leaders but to all members of the profession. In the development of key competencies, it is recognized that physiotherapists in public health institutions, as well as those in private practice, significantly need leadership skills and knowledge in order to conduct their professional practice. Interestingly, back in 2015, the Australian Association of Physiotherapists, in its report on the future of the physiotherapy profession, discussed the need for strong leadership to compete for resources, encourage innovation in theory and practice, and successfully promote the profession.
One of the concepts of leadership that is mentioned in the context of wider health care as well as in physiotherapeutic practice, is distributive or, as it is also recognized in the literature, shared leadership. As a concept, distributive leadership is not quite clearly defined. Gronn characterized distributive leadership as coordinated action, achieved through spontaneous collaboration, intuitive workplace relationships that develop over time, or institutionalized practice [24,25]. Distributive leadership shifts the focus from the characteristics and behaviors of the individual leader to a systemic perspective, where “leadership” is conceived as a collective social process that arises through the interactions of multiple participants [26]. Distributive leadership is closely related to teamwork [27]. In particular, teamwork in teams, where knowledge and ideas can be shared among team members, thereby influencing each other, is often considered important for improving and maintaining service quality [28,29]. Given that leadership in health activities, especially in the rehabilitation institutional environment, requires the establishing and maintenance of relationships through interrelated health and clinical areas and managerial roles, it can be seen as divided and distributed through the system [30]. It is shared or distributed: within the organization of institutions “from board to department, through various disciplines within teams and through social protection organizations, local government, the volunteer sector and a large number of other agencies [30]. It differs from traditional forms in that responsibilities are distributed, and some see it as a path to clinical-managerial distribution in complex health care [31]. It is necessary to understand the practice of leadership and organizational interventions, and not a simple and traditional leader-follower relationship [31]. It also requires multi-level staffing. There is a strong evidence base that staff engagement benefits both individuals and organizations, supporting wider acceptance of distributed leadership [32]. According to the Kings Fund, a think tank established by the British Parliament, distributive leadership has become the mainstay of health policy in the UK, and it is argued that it will be necessary for "the leadership of the 21st century health system to be shared. distributive and adaptive” [33]. At the core of shared leadership is Self-Leadership. Leaders must be effective self-leaders, which means that they must understand themselves, their influence on others and develop the ability to self-control, self-regulate and manage themselves. A leader must learn to lead himself before he acquires the ability to lead others in a team or organization.
Self-leadership and shared leadership are connected by their character because self-leaders willingly and enthusiastically accept common leadership roles and responsibilities in order to function complex organizational systems [35]. This certainly can be applied to work in interdisciplinary and multidisciplinary teams in rehabilitation, which is a very common work environment of physiotherapists.

APPRECIATIVE MANAGEMENT AND EMPOWERMENT

In considering leadership theory and its development, it is important to consider both the complementary and contradictory process with which it is so often associated, and that is management. A certain balance is needed in defining the differences between leadership and management but also recognizing certain overlaps between these categories [36]. An individual can be a manager without showing leadership or he can be a leader without being in a managerial role [16].
Management deals with the complexity of a system, planning, allocating resources, organizing and staffing, and controlling and solving problems, thus ensuring order and consistency [37]. Leadership deals with coping with change, setting the direction, guiding and motivating people [37]. When it comes to health facilities, it is often difficult to distinguish between leadership and management because many roles require managers to lead and leaders are expected to manage [38]. Healthcare professionals must constantly adapt to the rapid pace of change in the modern healthcare environment while still providing high quality healthcare services according to ethical principles [39]. Appreciative management is an energetic and efficient approach in encouraging organizational change, originally developed and applied in the business world in order to improve organizational culture, efficiency and profit [40]. When it comes to the health care system, it is a new management concept with a focus on employees [41]. According to the existing literature, it is a way of management where professionalism, cooperation, interaction skills and employee support are especially valued and emphasized [42]. Appreciation management also involves management support for the professional development of their employees [43]. Respectful leadership as part of appreciation management consists of trust, transfer of responsibility, taking into account people's needs, maintaining professional distance, respect, responding to mistakes collegially and with empathy, encouraging autonomy, promoting equality, encouraging development, openness to advice, acceptance criticism, stimulating potential, seeking participation, personal interest, reliability, attention, supportive and friendly interaction [44]. The features of appreciation management can be found in studies concerning professional activity and development in physiotherapeutic practice. According to the results of a Finnish study that examined aspects of positive-appreciation management in the work environment of physiotherapists in the public and private sectors, it was found that the most developed dimension is equality and that aspects of leadership and autonomy are more recognized in managers whose basic education is in physiotherapy [45]. A study dealing with the professional development of physiotherapists in the private sector in Australia, showed that physiotherapists who have recently graduated show a need for professional development. However, they also experienced conflicts with their superiors, because the promised support in their professional development was lacking [46]. It is an undeniable fact that in the field of physiotherapy there is a need to strengthen leadership and applied management. According to Tebbitt, "Empowerment means creating and maintaining a work environment with qualities (values) that facilitate the choice of employees to invest in their own activities and behaviors that result in positive contributions to the organization's mission." He also believes that empowering employees is a crucial factor for an organization to achieve its mission, vision and strategic direction, especially in terms of organizational change. Empowering work environments are those in which employees have access to information, in which the support and resources needed to do the job are available, as well as those that provide opportunities for the growth and development of knowledge and skills [48]. Furthermore, he states that there are three structural organizational sources of power: access to information lines, support, and resources. In order for individuals to be empowered, they need to have access to the knowledge and information necessary to do their jobs. This refers to information directly related to their work, but also information about the work of the organization as a whole. Support stems from feedback and instructions received from superiors, equal in status and subordinates. Access to resources for employees means that there is the possibility of obtaining the materials, money and recognition needed to meet job requirements [49].
Empowerment means that leaders actively encourage and stimulate employees towards self-leadership [50]. Strengthening work organization, by definition, is the activity of empowering employees by providing their autonomy, discretion, control, decision width or strength. Examples of empowering leaders' behavior include encouraging participatory decision-making, leading by example, sharing information, training, and showing concern for employees [51]. In response to this behavior, employees can be expected to feel more empowered and with a strong sense of contribution, control, competence, connection, and meaningfulness [51]. Access to resources, information and support lead to increased organizational commitment, reduced level of professional burnout, increased sense of autonomy in work, increased perception of participation in management, increased job satisfaction. According to numerous studies, physiotherapists are the primary candidates for burnout at work due to close contact with patients or clients in the work environment [52]. A characteristic of a good team is the ubiquitous sense of support, security and self-confidence, where members can rely on each other in difficulties and take creative risks, confident in the support of their associates. . Helping colleagues maintain a professional reputation is one of the valued qualities of good teammates. It is these rules of interpersonal relationships in the workplace that develop the key performance of the work team and the development of self-confidence in physiotherapists [52]. All this results in: achievements and success, cooperation in the organization, patient / client satisfaction [53].

CONCLUSION

Leadership, administration, management and professionalism are part of every form of physiotherapy practice. They are the basis for organizing the work of every health activity and represent the basis for the growth and development of health services it provides. It is important that managers in physiotherapy recognize the characteristics of appreciation-positive management, so they can implement them to become part of their practices and part of their own leadership style. Leaders in physiotherapy practice should be encouraged to educate themselves in the field of management and participate in the education of others. Leadership, self-leadership, shared leadership and positive-appreciation management with empowerment are interrelated aspects of management and functioning in teamwork and are therefore extremely important for physiotherapy practice. It is considered that one of the preconditions for successful management of the work process is the treatment of colleagues in a positive and consistent way, and the key feature of good teamwork is the ubiquitous sense of support, security and trust, where members can rely on each other in difficulties and take creative risks. , confident in the support of their associates. Mentioned interpersonal relationships develop key characteristics of a successful work team and develop self-confidence among physiotherapists.

LITERATURE:

1. WHO. Human resources for health. Toolkit on monitoring health systems strengthening. Dostupno na: https://www.who.int/healthinfo/statistics/toolkit_hss/
   EN_PDF_Toolkit_HSS_HumanResources_oct08.pdf  Preuzeto: 24.12. 2020.
2. Koerner M. Mental strain among staff at medical rehabilitation clinics in Germany. Psychosoc Med 2011; 8:45-67.
3. Fiabane E, Giorgi I, Musian D, Sguazzin C, Argentero P. Occupational stress and job satisfaction of healthcare staff in rehabilitation units. Medicina del Lavoro 2012;103(6):482-92.
4. Schafer DS1, Lopopolo RB, Luedtke-Hoffmann KA. Administration and management skills needed by physical therapist graduates in 2010: a national survey. Phys Ther. 2007;87(3):261-81.
5. Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:7–746.
6. McAlearney AS. Leadership development in healthcare: a qualitative study. J Organ Behav. 2006;27(7):967-82. doi.org/10.1002/job.417
7. Griffiths D, Sheehan C, Debar S, Ayres B. Colin-Thorne D. Clinical leadership – the what, why and how. In: Stanton E, Lemer, C. Mountford J, (eds.) Clinical leadership – Bridging the divide. London, UK: MA Healthcare Ltd, London. 2010.
8. Millward L. J, Bryan K. Clinical leadership in health care: a position statement. Leadership in Health Services 2005;18:13-25.
9. Edmonstone, j. What is clinical leadership development? . In: Edmonstone, J. (ed.) Clinical Leadership: A Book of Readings. Chicester, UK: Kingsham Press 2005.
10. Storey J, Holtie R. Possibilities and Pitfalls for Clinical Leadership in Improving Service Quality, Innovation and Productivity, Final report. Southampton, UK: NIHR Service Delivery and Organisation programme 2013.
11. Calpin-Davies PJ. Management and leadership: a dual role in nursing education. Nurse Educ Today 2003;23(1):3-10. doi.org/10.1016/S0260-6917(02)00157-0. Medline:12485564
12. Sonnino RE. Professional development and leadership training opportunities for healthcare professionals. Am J Surg. 2013;206(5):727-31. doi.org/10.1016/j.amjsurg.2013.07.004. Medline:24011565
13. Canadian Physiotherapy Association Leadership Division. Framework for Professional Development of Leadership Core Competencies Ottawa: Canadian Physiotherapy Association 2012.
14. Yukl G. Leadership in Organizations, Pearson, NJ. 2010.
15. James KT. Leadership in context: lessons from new leadership theory and current leadership development practice. London: King's Fund 2011.
16. Kouzes JM, Posner BZ The Leadership Challenge. 5th Ed.”, Jossey-Bass, San Francisco, CA. 2013.
17. Malloch K. Innovation leadership: New perspectives for new work. Nurs Clin North Am. 2010;45(1):1-9. doi.org/10.1016/ j.cnur.2009.10.001.
18. Desveaux L1, Nanavaty G, Ryan J, Howell P, Sunder R at all. Exploring the concept of leadership from the perspective of physical therapists in Canada. Physiother Can. 2012;64(4):367-75. doi: 10.3138/ptc.2011-42.
19. Stanley d J, Clinical leadership and innovation. Journal of Nursing Education and Practice 2012;2:119-126. doi.org/10.5430/jnep.v2n2p119
20. Hiscock M, Shuldham C. Patient centred leadership in practice. J Nurs Manag. 2008;16(8):900–4. doi.org/10.1111/j.1365-2834.2008.00961.x
21. Desveaux L, Verrier MC. Physical therapists' perceptions of leadership across the health care continuum: A brief report. Physiotherapy Canada. 2014;66(2):119-23.
22. CSP. 2012a. The contribution of physiotherapy management and leadership in healthcare [Online]. JJ Consulting for Chartered Society of Physiotherapy Available on: http://www.csp.org.uk/publications/contribution-physiotherapy-management-leadership-health-care-briefing-paper-physiothera 2015.
23. The future of physiotherapy in the health system .Australian Physiotherapy Association. Dostupno na: https://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/
    Resources/PublicPractice/InPublic_2025_updated%20150925.pdf Preuzeto: 24.12. 2020.
24. Gronn PC. Distributed leadership as a unit of analysis. Leadership Quarterly. 2002;13(4):423-451. doi.org/10.1016/S1048-9843(02)00120-0
25. Boak G1, Dickens V, Newson A, Brown L. Distributed leadership, team working and service improvement in healthcare. Leadersh Health Serv (Bradf Engl). 2015;28(4):332-44. doi: 10.1108/LHS-02-2015-0001.
26. Bolden R. “Distributed leadership in organizations: a review of theory and research”, International Journal of Management Reviews 2011;13(3):251-69.
27. Day D.V, Gronn P, Salas E. “Leadership capacity in teams”, The Leadership Quarterly 2004;15: 857–80.
28. West M.A. and Lyubovnikova J. “Illusions of team working in health care” Journal of Health Organization and Management 2013;27(1):134-42.
29. Ezziane Z, Maruthappu, M, Gawn L, Thompson E.A, Athanasiou T, Warren O.J. “Building effective clinical teams in healthcare” Journal of Health Organization and Management 2012;26 (4):428-36.
30. James KT. Leadership in context lessons from new leadership theory and current leadership development practice. Commission on Leadership and Management in the NHS The King’s Fund. 2011.
31. Turnbull James K. Leadership in context lessons from new leadership theory and current leadership development practice. Commission on Leadership and Management in the NHS The King’s Fund. 2011.
32. Rayton B, Dodge T, D’Analeze G. Employee engagement: the evidence. Engage for Success Report. 2012.
33. Kings Fund. The future of leadership and management in the NHS: no more heroes. 2011 09/11/15. Report No.) (Martin G, Beech N, MacIntosh R, Bushfield S. Potential challenges facing distributed leadership in health care: evidence from the UK National Health Service. Sociology of health & illness. 2015;37(1):14-29.
34. Houghton J D, Neck C P. Manz C.C. Self-leadership and superleadership. Shared leadership: Reframing the hows and whys of leadership 2003:123-140. doi:10.4135/9781452229539.n6
35. Shared Leadership Underpinning of the MLCF. Institute for Innovation and Improvement Academy of Medical Royal Colleges Preuzeto: 08.04.2020. Dostupno na: https://www.fmlm.ac.uk/resources/shared-leadership-underpinning-of-the-mlcf
36. Hartley J, Benington J, Leadership for healthcare, Bristol, UK, Policy Press. 2010.
37. Kotter J. P, What leaders really do. Harvard Business Review 1990;68:103-11.
38. Halligan P. Leadership and Management Principles. In: BRADY, A. (ed.) Leadership and Management in the Irish Healthcare Service. Dublin: Gill and Macmillan Ltd 2010.
39. Eagar SC, Cowin L S, Gregory L, Firtko A. Scope of practice confl ict in nursing: A new war or just the same battle? Contemporary Nurse 2010;36(1–2):86–95
40. Carter CA, Ruhe MC, Weyer S, Litaker D, Fry RE, Stange KC. An appreciative inquiry approach to practice improvement and transformative change in health care settings. Qual Manag Health Care. 2007;16(3):194-204. doi: 10.1097/01.QMH.0000281055.15177.79. PMID: 17627214.
41. Harmoinen M, Niiranen V, Helminen M, Suominen T. Arvostava johtaminen terveydenhuollon henkilökunnan ja johtajien näkökulmasta (Appreciative management from the viewpoint of staff and managers in health care. English abstract). Tutkiva Hoitotyö (Nursing Evidence) 2014; 2(2):36–47.
42. Harmoinen M, Niiranen V, Suominen T. Kirjallisuuskatsaus arvostavaan johtamiseen (Literature review of appreciative management. English abstract). Hoitotiede ,Journal of Nursing Science 2010;22(1):67–78.
43. Harmoinen M, Niiranen, K., Niiranen, V., Åstedt Kurki, P., Suominen, T. Stories of management in the future according to young adults and young nurses. Contemporary Nurse 2014;47(1–2):69–78.
44. Van Quaquebeke, N., & Eckloff, T. Defining respectful leadership: What it is, how it can be measured, and another glimpse at what it is related to. Journal of Business Ethics 2010;91:343–58.
45. Niemi R, Roos M, Harmoinen M, Partanen K, Suominen T. Appreciative management assessed by physiotherapists working in public or private sector: A cross sectional study. Physiotherapy Research International; 2018. DOI: 10.1002/pri.1724
46. Davies J, Edgar S, Debenham J. A qualitative exploration of the factors influencing the job satisfaction and career development of physiotherapists in private practice. Manual Therapy 2016;25:56–61. Dostupno na https://doi.org/10.1016/j.math.2016.06.001
47. Tebbitt BV. Demystifying organizational empowerment. J Nurs Adm. 1993:23(1):18–23.
48. Kanter RM. Men and Women of the Corporation. 2nd ed. New York, NY:Basic Books; 1993.
49. Miller PA, Goddard P, Spence Laschinger HK. Evaluating physical therapists' perception of empowerment using Kanter's theory of structural power in organizations. Phys Ther. 2001;81(12):1880-8.
50. Manz Charles C, Henry P. Sims. "Leading Workers to Lead Themselves: The External Leadership of Self- Managing Work Teams." Administrative Science Quarterly 2020;32(1):106-29. doi:10.2307/2392745.
51. Pearce C.L. Sims H.P. Jr“Vertical versus shared leadership as predictors of the effectiveness of change management teams: an examination of aversive, directive, transactional, transformational, and empowering leader behaviors”, Group Dynamics: Theory, Research, and Practice 2002;6(2):172-97.
52. Jovanović S, Stojanović B. Effect of stress and professional burning on moral values in physiotherapy profession ,Pons medicinski casopis 2017;14(2):52-58.
53. Laschinger HK. A theoretical approach to studying work empowerment in nursing: a review of studies testing Kanter's theory of structural power in organizations. Nurs Adm Q. 1996;20(2):25-41.