The Servant-Leadership Worldview in Long-Term Care Nursing

The goal of many leaders is to get people to think more highly of the leader. The goal of a great leader is to help people to think more highly of themselves.

J. Carla Nortcutt¹

The competitive U.S. healthcare market today needs ethical, competent nursing leadership to ensure quality healthcare delivery to our citizens. As our population ages, the need for skilled professional nursing is expected to rise, resulting in a projected 29% shortfall of nurses by the year 2020.² Much of this nursing care will be provided in long-term care facilities (LTCFs). Most LTCFs are already experiencing challenges with high nursing staff turnover rates.³ The problem of attracting and retaining dedicated nursing staff to work in LTC may be due to a multitude of factors such as image problems, lower wages, and voluminous regulations that micromanage and often thwart professional creativity.

Long-term care nursing has traditionally suffered from a public relations problem.⁴ Rather than recognizing and promoting the autonomy available to the LTC nurse, the view toward the nurse in this practice setting is associated very near the bottom rung of the glamorous professions ladder. In addition to this unmerited image issue, LTCFs in the United States are largely dependent on Medicare and Medicaid for funding, making it very difficult to financially compete with hospitals and other high-revenue settings in providing attractive nursing salaries.⁵

Long-term care facilities are also more heavily regulated by states and the U.S. federal government than any other type of healthcare provider.⁶ The regulations command volumes of paperwork, which takes nurses away from more rewarding patient-centered duties. The LTC annual survey process may be viewed as demoralizing by nursing staff, as surveyors are trained to focus on negative or “deficient” practice.

While salaries, image, and regulatory factors may not easily be changed, a significant opportunity to alter LTC nurses’ job satisfaction may lie within the power of the LTC nurse leader. The leadership style of a nurse’s immediate supervisor has been identified as a significant factor in job contentment and retention of registered nurses.7

The Servant-Leadership Model

The theoretical model of servant-leadership, as first described by Robert Greenleaf,⁸ will be examined here as a model for its inherent relationship to the service profession of nursing (Table). Servant-leadership goes well beyond a simple shared governance structure; it has the potential to transform culture within long-term care.

The definition of servant-leadership simply places serving of others as the number one priority.⁹ Greenleaf⁸ believed that the key difference between servant-leadership and other leadership models was found in the motivation of the leader.¹⁰ Servant-leaders are drawn to a purpose greater than themselves.¹¹

Listening

Servant-leaders make a commitment to listen to others. The opinions and ideas of others are sought and valued. Servant-leaders are also encouraged to listen within and to seek self-understanding. Nurses in conventional LTC leadership and management positions may not have placed importance on developing this skill. Top-down organizations generally stress authoritarian decision making, accountability, and outcome-driven performance. Ideas for improvement are not traditionally solicited from direct caregiving staff. The traditional, no-questions-asked, command-and-control method of leadership leaves no room for staff to express creative ideas. Listening is also important in the face of conflict. The ability of the servant-leader to guide staff through conflict is a skill worth developing. A culture of open communication encourages participation at all levels and helps to foster emotional investments and build a culture of community.

Empathy

Greenleaf⁸ recognized the basic need of human beings to be viewed as individuals. He said that the servant-leader strives to understand and empathize with others. He also promotes empathy within. One corporation that promotes empathy is Southwest Airlines, which does so by having pilots spend time in support staff areas, wearing the uniforms, and doing the tasks of the ramp crew.¹¹ Long-term care nurses may consider building empathy by following this example with the nursing assistants who provide much of the routine hygienic care.

Empathy also implies acceptance of all members of the team even when certain behaviors may not be accepted. Understanding the root cause of unacceptable behaviors often leads to developing strategies to help the staff member improve. Many nurse-leaders in LTC settings have had the experience of rising from within the ranks. It is wise, then, for the servant-leader to remember firsthand the difficult demands placed on the staff nurses and nursing assistants. The leader may then utilize empathy by drawing on his or her own experience while interacting with staff.

Healing

The concept of healing is central to the consciousness of nursing as a profession. Greenleaf⁸ postulated that human beings are in search of wholeness. He said that the servant-leader has an opportunity to contribute to the completeness of others by serving as a healing force between them. A healing spirit strives to be a therapeutic agent. This concept is far removed from traditional organizational culture, where interpersonal conflicts are seen as disruptive forces to be dealt with in a punitive manner. Long-term care nurses often experience grief when faced with the death of a resident. This human reaction can be viewed as an opportunity to acknowledge the value of the spirit within each individual.

Awareness and Perception

Greenleaf¹² said that awareness helps one understand issues of power, ethics, and values. Awareness in thought helps one integrate multiple factors in formulating a holistic position. A servant-leader must be open to information from multiple sources. According to Greenleaf,⁸ “the cultivation of awareness gives one the basis for detachment, the ability to stand aside and see oneself in perspective, in the context of one’s own experience.” He went on to say that servant-leaders are usually sharply awake and reasonably disturbed by what they experience. This keen awareness enables leaders to formulate priorities and anticipate needs. The LTC nurse leader must continually be aware of the changing needs of the interdisciplinary team and of the residents they are serving, as well as aware of a myriad of issues. Factors such as adequate staffing, skill sets of the staff, availability of supplies, reimbursement, census, residents’ rights, coordination of care, needs of families, and demands of administrators are but a few issues that the LTC nurse leader must deal with.

Persuasion

Servant-leaders rely on their powers of persuasion rather than rank and authority in making decisions within an organization. The servant-leader seeks to convince rather than coerce. Consensus building is a skill that builds a culture of cooperation and harmony. Greenleaf⁸ said that sometimes persuasion is effective “one person at a time.” In the nursing profession, persuasion is strongly correlated with the staff opinion of the nurse leader.¹³ The nurse leader who is viewed as being empathetic, fair, consistent, open to questions, and reasonable is able to effectively utilize powers of persuasion in working with others. Nurse servant-leaders consciously surrender the ideas of exertion of strict power, authority, and control in favor of this more inclusive concept of persuasion. In the LTC nursing environment, a nurse leader may seek to use persuasion rather than dictating details of how specific tasks are accomplished and documented. For example, staff schedules, resident activity calendars, and clinical assignments are all areas of possible negotiation and consensus.

Conceptualization

Every great improvement begins with an idea or a vision. The servant-leader seeks possibilities and sees not only what is there, but sees how things could be. Conceptualization forms the basis for one to think beyond traditional ways of delivering care. Effective LTC servant leaders strive to bring fresh approaches to enhance quality of care and quality of life for the patients and staff they serve.

Foresight

The ability to see beyond the day-to-day tasks and lead a nursing team into the future is another characteristic of the effective servant-leader. Spears¹⁴ said that foresight is the ability to see ahead and project the likely outcome of a situation. Some LTCFs have organizational cultures that are open to development of new ideas, providing the garden in which the roots of insight and foresight may be planted and grown. Foresight appears to be closely linked with other traits of the effective servant-leader, such as listening, awareness, and perception. In spending the time and energy to critically examine the nursing teams’ present activities and goals, the path toward the future (foresight) may become evident. Certainly, LTC leaders will need foresight to creatively and effectively plan for the future healthcare needs of our aging population.

Stewardship

Block¹⁵ described stewardship as holding something in trust for others. This concept is often seen in religious organizations, where there is an awareness of life beyond today and of service to a greater purpose. The concept of stewardship in healthcare is no less applicable. While many private organizations place paramount importance on their fiscal responsibilities to their shareholders, servant-leader–led organizations see an even greater moral imperative to do good work. Healthcare is a humanitarian endeavor, and nurses are the largest segment of providers of healthcare in this country. The values of care and compassion associated with the dedicated bedside nurse should easily be congruent with nurse servant-leaders’ attitude toward stewardship and leadership. In the LTC setting, stewardship is demonstrated in acts of succession planning and in policies that include provisions for the future.

Commitment to the Growth of People

Servant-leaders believe in the intrinsic value of human beings. This value extends beyond the work they produce.¹⁴ Servant-leaders are devoted to the development of individuals within the organization. They feel a deep commitment to improve the lives of others. In LTC nursing, this may be accomplished by providing funding for education, on-site childcare benefits, or flexible scheduling to encourage a work-life balance. Promoting the growth of others may also be accomplished by recognition of the unique talents of others and the willingness to promote staff from within the organization.

Building Community

This final characteristic identified by Greenleaf8 refers to creation of kinship within the workplace. In a community, each member is valued and encouraged to contribute to the whole. While current popular leadership literature may describe gimmicks to foster cohesiveness (eg, departmental contests, logos, t-shirts, casual Fridays), I believe that a deeper sense of commitment and community is inherent in the LTC workplace. In this home-like environment, staff is privy to the most intimate details of the lives of those they serve. Deep human connections in this microcosm are not the exception but rather the rule. Stresses, encountered daily in the LTC environment, tend to build bonds as the staff—and residents—turn to each other for support.

Conclusion

The main principles of the servant-leadership model may easily be applied in the LTC nursing setting. This alternative to the traditional power-based approach encourages collaboration and valuation of all workers. As seen in other corporate sectors, this style of management has the potential to greatly improve worker satisfaction and dedication. Nursing leadership organizations and educational institutions would do well to promote the professional satisfaction by endorsing servant-leadership across healthcare settings. Long-term care nursing facilities may be poised to shake off their old image and serve as nursing practice innovators of excellent servant-leadership in action.

The author reports no relevant financial relationships.