By identifying and documenting the behaviors required for RCPs to be successful in the new health care marketplace, satisfaction among customers, patients, and stakeholders can be greatly improved.

“No man is free who cannot command himself.”

For years, respiratory care educators have pursued the minimum acceptable criteria for safe performance of certain tasks and duties. In other words, we have attempted to measure outcomes based on the minimum definition of success. While this view is important, it provides only a glimpse of the threshold required to be a safe practitioner, not necessarily a successful one. As we continue to develop practitioners or aspiring practitioners only toward a specific set of knowledge, skills, and abilities, we fail to explain for them what behaviors we need, require, or even expect.

A study conducted in 1999 proposes a different view.1 Rather than focus on the minimum threshold, this study suggests that there is a set of differentiating behaviors that separates the successful RCPs from the minimally “safe” ones. Rather than develop existing practitioners only toward a minimum model of practice, is it not sensible to also develop them toward a more definite model of success? The current approach can only prevent dissatisfaction in the health care marketplace. By ensuring a minimal level of knowledge and skill, we just improve the chances that no one will be injured as a result of inappropriate care. By identifying and documenting the behaviors required for RCPs to be successful in the new health care marketplace, however, we greatly improve our chances of creating satisfaction among our customers, our patients, and our stakeholders.

Perhaps an analogy will illustrate this point. The best dentists in the world did not achieve their status by only being expertly skilled in reading oral x-rays, identifying cavities, filling teeth, and extracting teeth. They must do these things in order to be a dentist. These are minimum criteria for professional practice and safety. Rather, the best dentists became “the best” by doing these activities while also managing patient relationships, keeping focused on the business needs of the practice, creating a safe and fulfilling work environment for their team, providing leadership in the dental profession, and managing certain “limiting” tendencies in themselves. These behaviors acted as differentiators to success rather than mere criteria for safe practice.

To further demonstrate this difference, we might look at a nursing example. In this study, a group of excellent nurses was asked to inject 100 patients. A control group containing somewhat lower-performing, although minimally acceptable, nurses was asked to perform the same injection on the same sample of 100 patients. The procedure was exactly the same; however, the patients reported feeling much less pain from the injections given by the study group than from the control group.

When the difference between the two groups was examined more closely, the researchers found that the groups of nurses performed exactly the same tasks, but the behaviors they demonstrated immediately prior to the needle stick were much different. For the most part, the control nurses introduced themselves briskly, many discounted the pain the patient would feel, and then plunged the needle into the skin with businesslike efficiency. The study group, however, used a somewhat different approach. These nurses were just as efficient with the needle, yet they set the stage much more deliberately and much more carefully. Acknowledging the pain the patients would feel, most of these nurses then assured the patients that they would be as gentle as possible. The excellent nurses in this study demonstrated the empathy competency, which resulted in a different outcome for the patients.2

Professional Competencies
Goleman described the “new yardstick” by which workers in America are being judged.3 That yardstick, as Goleman explained, is focused on measuring how well employees handle themselves and relate to other people. Gone are the days of merely relying on our training, our technical expertise, or our IQ. These new rules for selection, development, and promotion more accurately predict who will become the star performers, as well as those more prone to becoming professionally derailed.

Professor David McClelland published a landmark paper in 1973 that questioned the value of intelligence in the work setting.4 This paper has been credited with launching the professional competency movement in psychology.5 In his paper, McClelland argued that traditional academic aptitude, grades, and advanced training and credentials did not positively correlate with superior job performance or professional success. Instead, McClelland suggested that a specific set of professional, behaviorally described competencies distinguished the “stars” from those who were merely able to retain their employment. To find these star performance competencies in any given job, McClelland suggested, one must begin by looking at the exemplars in that job and determining what competencies they display.

McClelland first tested these methods with US State Department Foreign Service Information Officers (FSIOs) and Massachusetts human service workers. With the FSIOs, the State Department found that a selection examination was not predictive of success. McClelland’s challenge was to answer this question: “If traditional aptitude measures from the FISO selection exam do not predict successful job performance, what does?” His approach to answering this question was first to select a criterion sample composed of several clearly superior performers and a contrasting sample of average and/or poor performers. These star performers were the most brilliant and effective young diplomats. They were rated by their superiors, peers, and foreign clients as the most effective diplomats in the United States. The contrasting sample was a group of average performers who did their job just well enough to keep from being fired—those the Foreign Service might prefer to have kidnapped by guerrillas.

In this study, the investigators discovered three broad professional competency characteristics that differentiated superior from average or poor performers. First among these competencies was the demonstration of cross-cultural and interpersonal sensitivity. This was defined as hearing what people (even those from a different country and/or culture) are really saying or meaning and predicting how they will act or react. Another competency difference was demonstrating positive expectations of others. The superior FISOs had a strong belief in the underlying dignity and worth of others different from themselves. They were also able to maintain and demonstrate this belief under stressful conditions. Finally, the investigators found that the stars were able to discover political networks very quickly. They could readily learn who influenced whom, as well as the political interests of each person.

Boyatzis identified a set of behaviorally described competencies that consistently distinguished superior managers across various organizations and functions.6 Among the competencies he found were achievement orientation, initiative, teamwork and collaboration, and analytical thinking.

A recent landmark analysis of thousands of people in jobs ranging from postal clerks to law partners shows the economic value of having a few professionally competent standout performers.7 These researchers compared the top performers—those in the highest 1%—with average or poor performers in terms of economic differences. They found that the economic value of the top performers increased considerably as the complexity of the jobs also increased. For simpler jobs like machine operators or clerks, those in the top 1% produced three times more than those in the bottom 1%. Among those workers performing jobs of medium complexity, like sales clerks or mechanics, a top performer was approximately 12 times more productive than a low performing counterpart (top 1% versus bottom 1%). Finally, rather than compare top performers in the most complex jobs (ie, lawyers, health care providers, account managers, insurance salespeople) against the bottom 1%, the researchers compared top performers to average performers (middle 1%) in these positions. Even with this difference in comparison, the performers in the top 1% were 127% more productive than those in the middle.

Recent work by Robert Kelley focused on “brain-powered workers” in a high-tech environment.8 In this study, Kelley asked managers and employees of a high-tech organization to nominate the high performers or the “stars” from their workforce. When the lists were compiled, the first finding that struck the researchers was that the lists of employees were almost completely different between the two groups (ie, managers and employees). This finding basically underscored the fact that there is not a clear understanding of what differentiates successful people.

Kelley was able to identify a small number of employees, however, that made both lists and used those “stars” as a study group. He analyzed such factors as cognitive intelligence (ie, IQ, logic, reasoning), personality factors (ie, self-confidence, risk-taking), and social factors (ie, interpersonal skills and leadership). Kelley provides this commentary on the findings: “Our data showed no appreciable cognitive, personal-psychological, social, or environmental differences between stars and average performers.… It wasn’t what these stars had in their heads that made them standouts from the pack, it was how they used what they had” (pp 9-10).

A number of studies have validated the fact that a large percentage of workers get jobs and advance in those jobs because of their attitude. Too often, professionals try to change the things over which they have no control and ignore those things that are most controllable, such as their attitudes.

A study of vice presidents and personnel directors at 100 of America’s largest companies revealed some interesting statistics. In this study, the leaders were asked to identify the single greatest reason for firing an employee. From those responses, the following top reasons were identified9:
• incompetence;
• inability to get along with other workers;
• dishonesty or lying;
• negative attitude;
• lack of motivation; and
• failure or refusal to follow instructions.

Although the top reason on the list was incompetence, studies have shown that many times decisions about employees’ “competence” were made based on factors that, in actuality, have very little to do with their technical knowledge, skills, or abilities.

Finally, a survey by the Carnegie Institute a few years ago analyzed the records of 10,000 successful people. Their conclusion was that 15% of success is due to education or training, and 85% is due to other factors such as professional competence.

Hypotheses for Success
A number of hypotheses have been formulated that describe those work factors, characteristics, or traits that will most likely result in success, regardless of your profession or discipline. Among those most commonly referred to in the literature are professional image, performance, dependability and reliability, willingness, effective communication, honesty and integrity, responsibility, and professional involvement.

• Professional Image
One of the most important elements of every professional is image. Having a professional image is what conveys to our colleagues that we are competent, serious, and able. It is the example we set for our colleagues or employees. It lends credibility to our ideas, suggestions, and solutions. Of all of the assets an RCP possesses, professional image has the direct potential to build or destroy a career. Image hinges on the degree of professional competency demonstrated by the RCP, and this professional competency can be described using very specific and observable behaviors.
The average patient has very little basis for judging competence. Nevertheless, most patients make such judgments, and they make them frequently. Most often, these judgments are based solely on appearance and personal interactions. This article will explore some of the “success literature,” and then introduce the RCP Success Model, which was built from research intended to identify the behaviors that RCPs must exhibit to be successful in the new health care marketplace of the 21st century.

• Performance
Performance is the sum of three basic variables: natural ability, acquired skill, and the desire to achieve.10 In addition, there are six basic attributes commonly found in high performers:
1. Peak performers have missions that motivate them to reach their highest potential.
2. Peak performers attain results because all their activity is devoted to achieving specific goals of their mission.
3. Peak performers use self-management, self-mastery, and the capacity to observe themselves and think effectively.
4. Peak performers are masters in team building and possess an ability to empower others.
5. Peak performers have great mental agility and a high level of concentration.
6. Peak performers anticipate and respond to major changes while maintaining their momentum.

• Dependability and Reliability
A person who cannot be depended on in the workplace commits professional suicide. Employers want leaders who can be counted on and who are reliable in terms of getting the job done. Leaders must be dependable as well. One way that leaders destroy their image among employees is in being undependable or unreliable. Employees expect to be able to count on the word of their leaders.

• Willingness
One of the statements from RCPs that is totally unacceptable is “It’s not my job.” As a professional, your job is to care for your customer (patient, employee, etc) in the most effective and efficient manner possible. This means having a willingness to help others in times of hardship or other circumstances. As health care moves toward a more collaborative model, the need for willingness is essential. Being available and willing to step outside your normal “square of responsibility” is very helpful in shaping a positive professional image.

• Effective Communication
A professional image is often hindered by the use of improper or inappropriate language and/or grammar. Early in secondary school we learn the proper means of oral communication, yet as we progress through life, we tend to ignore it in practice. We resort to double negatives, improper contractions, and slang. The health care professional absolutely must hone the skills of effective communication.

• Honesty and Integrity
One of the quickest ways to destroy a professional image with both employers and colleagues is by dishonesty or lying. You do not have to be a fundamentally dishonest person; you only have to create that perception in someone’s mind. Understanding the importance of character and integrity is a must for the rising leader. Employees can very easily detect a breach in honesty and integrity in their leader. Although this detection may not be vocalized, it is there. And, if not acknowledged and dealt with, it infects, contaminates, and will eventually destroy any hope of professional trust and/or respect. Credibility is a must with employees; honesty and integrity are the nutrition of professional credibility.

• Responsibility
Individual achievement is directly related to a person’s ability to take full responsibility and hold himself accountable for his own actions.11 Many times, health care professionals do not feel in control of their professional practices and directions. This leaves many of them feeling helpless and frustrated. However, the feelings of being in control or having the power to influence one’s professional environment come from having a positive self-image, rather than from specific environmental, organizational, or situational factors. For the most part, health care providers tend to focus their frustrations over not feeling in control on these external factors rather than on developing a positive self-image.

• Professional Involvement
Your professional fulfillment and satisfaction are directly related to your specific contributions to the profession.12 This basically means that you experience reward from the profession only after you have made a contribution to it. You receive gratification and fulfillment only to the degree that you make active and significant contributions. If you make small and inconsistent contributions to the profession, you will experience only small and inconsistent gratification. Conversely, if you make a sustained and substantial contribution, you will experience a consistent and significant feeling of career satisfaction and fulfillment.

Professional satisfaction comes only after you take the risk of investing your time, efforts, and energy to do something that is over and above what is required. So many health care professionals are “on the take.” What can my profession do for me? What can my organization or department do for me?

When you make sacrificial contributions without concern for pay or recognition, you begin receiving the feelings of professional fulfillment and satisfaction. If you expect only to put in your time, without doing anything extra, you will be ultimately dissatisfied. Some professionals never learn this valuable lesson. They participate in a profession for many years, waiting to be fulfilled or gratified so they can then make a professional contribution. They have the process backwards. You do not experience reward by just doing what is expected. You experience reward by doing your best.

One of the most important practices of the successful RCP is continued, active involvement and participation in professional organizations, even if your employer does not pay your membership dues, or does not pay for you to attend professional meetings and seminars. Professional membership is a responsibility, not a privilege. And it is your responsibility, not your employer’s.

Validating RCP Success
American business organizations began realizing the value of professional competency models during the 1970s. American health care organizations have been much slower to embrace the concept.

Technical knowledge, skills, and abilities are absolutely necessary for safe and reliable performance as a RCP. The literature suggests, however, that these threshold factors do not distinguish superior or even successful performance. In order to close the gap in respiratory care research, this work defines a specific set of observable behaviors that will contribute to the success of RCPs in the near and distant future.

This study sought to identify the “success” competencies for RCPs moving into the 21st century with its changing health care landscape. Another goal of this research was to arrange these competencies into a model that would render them useful for managers, practitioners, and educators.

The following actions were taken in order to accomplish the goals of this study:
1. Reviewed the literature on respiratory education and competency development in both business and health care.
2. Selected a panel of highly qualified experts in respiratory care to participate in the data collection portion of the study.
3. Developed a list of “starting competencies” from the literature and from an initial open-ended survey of the expert panel.
4. Created and administered a three-round Delphi survey instrument that asked the experts to score each behavior with regard to its critical nature in the practice of respiratory care and then asked them to identify the knowledge, skills/abilities, and attitudes that would make consistent demonstration of these behaviors possible.
5. Analyzed all responses from each round of the Delphi and reported them back to the panelists in subsequent rounds, asking them to reconsider their responses on any items where consensus was not achieved.
6. Constructed a “success model” based on the data collected from this panel.

Previous studies into the needs of the RCP have remained primarily focused on educational needs. The focus on identifying the behaviors, or the outcomes, of high performance has eluded researchers in the past.

The Delphi Technique was chosen because of its previous use and appropriateness in situations that do not lend themselves to precise and complex analytical or statistical techniques. Additionally, the method was chosen in order to prevent any biasing of the data that might result from focus group interviews where group dynamics are a factor. Finally, the Delphi allowed the achievement of group consensus, based on the professional judgment of a national sample of expert panelists, without the time and expense required to convene focus group sessions.

The expert panel was chosen from 102 potential candidates who were invited to participate on the basis of several predetermined professional criteria. The panel was composed of experts who had between 15 and 50 years of respiratory care-related experience, with a total of 982 years of experience (mean = 25.18 years).

Panelists responded to an initial survey where they were asked to consider the changing health care environment and to identify the behaviors required of RCPs to be successful in this new environment. In addition, they were asked to provide certain demographic information with regard to their position, education, job role, experience, etc.

Results were analyzed and compiled from this first round survey and used to develop the second round in which the panelists were asked to consider the 239 professional behaviors identified in the previous round. The panelists were then asked to score the behaviors with regard to their critical nature for all RCPs, regardless of their position, in this new health care environment.

This approach was continued until consensus was achieved on a specific set of professional behaviors that would ultimately be used to construct the RCP Success Model. All behaviors in the model, therefore, were identified by the panelists as critical for all RCPs. The level of consensus required for a behavior to be included in the RCP Success Model was 75%.

A cluster analysis allowed the grouping of similar behaviors into competency categories, making them easier to both understand and relate to practice. When the grouping of these behaviors was finalized, 11 distinct competency categories emerged (see Figure 1).

Competency Consensus Competency Consensus
Business Orientation 98.5% Leadership 93.2%
Communication 96.3% Continuous Learning 92.2%
Professionalism 96.0% Quality Orientation 90.4%
Empathy 95.6% Self-Management 90.2%
Respiratory Care Practice 95.5% Customer Service Orientation 87.2%
Teaming and Collaboration 93.3%    
Figure 1. Competencies and expert panel consensus findings.

These competencies are listed in order of significance based on the expert panel consensus levels that were achieved. In other words, business orientation received the greatest level of consensus across all related behaviors and customer service orientation received the least degree of consensus across all related behaviors. A listing of these competencies, along with expert panel consensus findings, is contained in Figure 1.

Each of these competencies is described by a set of specific and observable behaviors. An example of the business orientation competency is also provided in Figure 2.

• Works within health care business rules and regulations
• Demonstrates an understanding of patient care economics and payment processes
• Consistently performs responsibilities in a manner which utilizes cost-effective, safe, and effective treatment modalities
• Utilizes knowledge and skills to best serve the client, provider, and payer populations
• Maintains a cost-effective approach to patient care
Figure 2. Business orientation.

Rather than advocating the need for a core curriculum, the results of our study seem to point toward outcomes, which have been the focus of respiratory care accreditation organizations for more than a decade. The outcomes suggested by this study, however, move beyond the normal expected clinical outcomes that center around the practice of respiratory care. While these clinical outcomes are important and should not be ignored, they are merely “threshold” outcomes and not “differentiators” of success.

To be successful in the future, respiratory care managers, educators, and practitioners must also embrace a differentiating rather than a threshold philosophy. They must attempt to create satisfaction rather than merely prevent dissatisfaction. With the drastic changes occurring in the health care landscape of the 21st century, the future stability of the profession could well depend on it.

Jeff Standridge, EdD, RRT, focuses on associate and organizational effectiveness at Acxiom Corporation in Little Rock, Ark. He holds an adjunct assistant professor position at the University of Arkansas for Medical Sciences, Little Rock, and previously served as president of the Arkansas Society for Respiratory Care. He can be reached at (501) 342-3217 or by e-mail at [email protected].

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