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Journal of Nursing Administration:
doi: 10.1097/

Servant Leadership: Enhancing Quality of Care and Staff Satisfaction

Neill, Mark W. EdD; Saunders, Nena S. RN, MN

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Authors' Affiliations: Assistant Professor (Dr Neill), Graduate Department of Educational Leadership and Instructional Design, Idaho State University, Pocatello, Idaho; Patient Safety Coordinator (Ms Saunders), George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah.

Corresponding author: Dr Neill, 921 South 8th Ave, Stop 8059, Pocatello, ID 83209-8059 (

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Servant leadership encompasses a powerful skill set that is particularly effective in implementing a team approach to the delivery of nursing practice. This model encourages the professional growth of nurses and simultaneously promotes the improved delivery of healthcare services through a combination of interdisciplinary teamwork, shared decision making, and ethical behavior. The authors describe the case application of servant leadership principles in a Department of Veterans Affairs Medical Intensive Care Unit located in a large urban center.

The unenviable image of the veterans affairs (VA) hospitals a little more than a decade ago was that of an antiquated, deteriorating facility, inadequately equipped, and understaffed by poorly trained healthcare workers. This system was widely regarded as a sprawling network of unsafe hospitals, managed by a top-heavy, scandal-ridden bureaucracy with little accountability.

In the past 10 years, the VA system has undergone a significant reengineering effort with dramatic results. The VA system is now considered to be a model hospital structure. The New England Journal of Medicine reported that the VA healthcare system improved substantially in the period from 1994 to 2000. Data indicated that patient satisfaction with the quality of care in the VA system was significantly better than that in the Medicare fee-for-service program.1 A similar conclusion reported by the Rand Corporation documented that VA patients consistently received more comprehensive healthcare services and follow-up and were more satisfied with the care they received.2

Over the past 5 years and within the VA system, the George E. Wahlen Veterans Affairs Medical Center in Salt Lake City (SLC), Utah, has consistently earned exceptional rankings on the quarterly Surveys of the Health Experiences of Patients report, an instrument that documents patient perceptions of healthcare on a variety of service standards.3 In the first quarter of fiscal year 2006, this facility scored in the highest quadrant on the performance measures report used by VA healthcare organizations across the United States.4 This, in part, has been attributed to the application of servant leadership principles across nursing departments, with an emphasis on improving the quality of healthcare services and increasing professional satisfaction.

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Servant Leadership in Nursing Practice

In the SLC facility, the Medical Intensive Care Unit (MICU) is a leader in employee fulfillment and patient satisfaction. The unit is acknowledged for its team-centered approach to the consistent delivery of high-quality patient care. Reinforcing this interdisciplinary team approach has been a unifying set of core values and a collective sense of collegial support among healthcare providers. Unit members put aside their individual ego, share a common sense of mission, and willingly assume responsibility for the unit's climate. The result has been a consistent high level of quality patient care and increased professional satisfaction in nursing practice among the healthcare team members.

Guiding this unit's cultural development has been the application of servant leadership principles under the direction of the nurse leaders. Servant leadership is founded on the belief that leading others has less to do with directing people and more to do with serving them. Servant leadership originates from a fundamental desire to serve and, as a result of that service, one is called upon to assume a greater leadership role.5,6 The ultimate aim of the servant leader is to meet the highest priority needs of those served.6

Servant leadership provided an opportunity for a unique mix of idealism and pragmatism. When applied to healthcare delivery, servant leadership is appealing on a deeper level because the application is based on the dignity and self-worth of all people and emanates from the democratic principle that a leader's power is generated from those who are led. Servant leadership is practical in the sense that only a leader who is competent and committed to the well-being of others can truly lead in the most difficult situations.7

The principles of servant leadership align well with the caring disposition inherent in nursing practice. When applied in this setting, servant leadership attempts to simultaneously enhance the personal growth of healthcare providers in practice while improving organizational effectiveness through a combination of teamwork and community building, shared decision making, and ethical and caring behavior,8 precisely the characteristics embodied in a quality healthcare system and one in which professional satisfaction is enhanced.

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Principles of Servant Leadership

Ten principles of servant leadership have been identified.8 These principles can be applied in nursing and interdisciplinary practice to enhance the delivery of high-quality healthcare and improve employee job satisfaction. These principles embody behaviors that can be learned and continually developed and/or exist naturally in some people.9 Included on the list of servant leadership principles are listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and community building.7,8

The application of servant leadership principles in the MICU represented a clearly focused effort to support enhanced delivery of healthcare services and improve professional satisfaction. These principles included the following.

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The ability to communicate effectively has frequently been identified as an important characteristic of exemplary leadership.5,6,8 Central to this skill is the ability to listen receptively to a variety of viewpoints. Servant leaders make a deep commitment to intent listening, seeking to identify and clarify the will of the group. The servant leader attempts to get in touch with his/her inner voice and frequently engages in regular periods of intense reflection.8

Within the MICU, the nurse leader created an environment that encouraged all ideas. The leader listened carefully to the articulated and unspoken messages shared by employees and creatively integrated these into elements of the unit's work. Based on a fundamental belief that everyone in the unit wanted and could contribute to organizational goals, the nurse leader translated reflective listening into meaningful action by identifying and generating opportunities for nurses to develop innovations to improve the delivery of healthcare services. The leader made it a central practice to credit staff members for successful improvements and innovations.

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The servant leader strives to understand the position and circumstance of others, makes a concerted effort to consider other's viewpoints, and helps followers realize their dreams. The servant leader assumes the good intentions of coworkers, recognizing and accepting them for their unique abilities and contributions. This does not suggest that unacceptable behavior or performance is condoned but rather that it is the behavior and not the individual that is sanctioned.

Guiding many decisions in the MICU was an overriding principle that the nurse leader would never ask a nurse to do something that he/she himself/herself would be unwilling to do. This message of selflessness resonated with nurses and communicated a level of empathy and support for every member of the unit.

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The healing of relationships is a powerful transformative process within any organization. The changing landscape of the healthcare industry has resulted in an erosion of the ethical and emotional relationships that nurses experience in the workplace.10 The servant leader has the capacity to heal many of these relationships, making whole the variety of emotional hurts and fractured spirits of others. This is particularly valuable in an industry that places healing at the center of its profession.

Nursing typically attracts a diverse mix of people from a variety of backgrounds. In the MICU, the nurse manager strategically identified the strengths of each member and carefully crafted opportunities for each of them to use these qualities within the unit's work. This effort resulted in unitwide acceptance of each individual and a dramatic increase in the confidence level of these valued team members.

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Awareness helps the leader understand the ethics, values, and power inherent in an issue from a more holistic and integrated position.8 An awareness of the values of the diverse constituents in the healthcare setting provides servant leaders with a deeper understanding of essential issues and is thus more likely to help the organization develop meaningful solutions to critical concerns.

Recognizing critical events in the lives of employees is fundamental to creating a supportive culture. In the MICU, these events were sometimes cause for serious concern; however, under the careful guidance of the nurse leader, the group was supportive of one another during these times, resulting in a more positive, familial, and caring culture.

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The use of persuasion rather than positional authority is another hallmark of servant leadership. Servant leaders become masterful at building consensus by capitalizing on the collective expertise of the group. Servant leaders are not interested in having their way but in finding the best way. They do not say, "Get going." Instead, they say, "Let's go!" and then lead the way.

Shared decision making is the norm in the servant-led organization. This does not imply that the leader abdicates a role in decision making, but more often, he/she assumes the role of a informed persuader, providing others with insight and strategies to successfully address concerns.

In the MICU, a unit council comprised of elected representatives of interdisciplinary healthcare professionals was charged with making unit decisions. An area of frequent conflict was the issue of visiting hours for families of patients. Many nurses expressed varying levels of discomfort with the presence of family during patient procedures. The leader was able to provide the unit council with research supporting the contributions that family members make to the recovery process of patients.11-13 The unit council subsequently decided to reduce visiting hour restrictions and support greater family involvement.

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Servant leaders think beyond present time urgencies to encompass broader based conceptual thinking. They avoid getting bogged down in operational matters and encourage a climate that values creative processes. Servant leaders are able to balance their current obligations with the continually evolving state of the industry.

In the MICU, the nurse leader operated on the premise that the day-to-day stresses such as medical emergencies, multiple and simultaneous admissions, or unplanned leave were more manageable when shared by the entire team. The leader purposefully regarded and communicated these moments as opportunities for nurses to advance their craft, exercise innovation, and contribute to improving the delivery of quality healthcare.

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Paralleling conceptualization is the ability of the servant leader to anticipate outcomes and integrate this thinking into effective decision making. Visionary leadership is a hallmark of most trait leadership models.14-16 Effective leaders consistently use a variety of viewpoints to provide a broader lens with which to predict the impact of a particular decision.

The nurse leader in the MICU frequently volunteered the unit as a site to pilot new technologies and clinical/medical trials. This technique provided nurses with a broader understanding of the big picture, an advanced look at emerging technologies, and an opportunity to witness the power of nurse input in fostering innovation and organizational improvement. Evidence-based practice was implemented to address clinical issues and improve the quality of care by continually enhancing the service process.

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Servant leaders demonstrate a strong sense of stewardship. This goes beyond the typical context of generating profit for the institution or even healing the sick. The servant leader meets this obligation by "building the capacity of the next generation to govern themselves."17 Servant leaders consider others as partners; they share rewards and glorify the team spirit. The servant leader realizes that some of his/her greatest responsibilities are to leave the organization in better shape than when he/she found it, prepare the organization to contribute to the greater good of society, and make a positive difference in the lives of people.

The nurse leader empowered the unit workforce to improve the quality of the healthcare services by continually sustaining a positive team spirit. An unwritten but underlying goal of each unit member was to consistently create an environment that was better than the day before for patients and nurses alike.

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Committed to the Growth of People

Servant leaders are people builders, deeply committed to nurturing the personal and professional growth of each individual in the organization. They provide strong, supportive mentoring relationships focused on growing greatness. Servant leaders lift others up, helping them to realize their dreams and maximize their potential. They recognize the value in the contributions of the people in the organization beyond their tangible contributions as workers. They help their people grow because they realize that the more "big people" an organization has, the stronger it becomes.

The servant leadership characteristic most readily evident in the MICU was the leader's commitment to the growth of people. This was accomplished through a conscious effort to recognize the unique talents of individual nurses and channel their development along those lines. This involved assigning nurses to projects or research efforts particularly aligned to their strengths and interests. The leader recognized the importance of taking care of the people who take care of the patients and continued to help nurses grow their skills and use them throughout the organization.

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Building Community

Central to a sense of community within an organization is an agreement of shared values and a common sense of purpose. The servant leader embraces these qualities but takes community building one step further. The servant leader focuses on meeting the needs of all interdisciplinary providers by balancing the needs of each rather than regarding them as competing interests. Like a community in the traditional sense wherein neighbors are helpful, supportive, and respectful of one another, the servant leader provides support for each provider's highest priority needs.

The servant leader creates opportunities for meaningful dialogue and recognition of member interdependence. Dialogue is the way human beings think together.18 Truly meaningful conversations occur in a culture of genuine trust and respect, based on a mutually identified mission, grounded in common principles, and cemented by the strength of these beliefs.19

The leader in the SLC MICU made a concerted effort to identify and recognize the needs and contributions of each interdisciplinary provider. Nurses, doctors, and support personnel were respected and valued equally. The leader visited regularly with patients, collecting information about the nature and quality of the care they received. Specific feedback was shared with individual nurses and supportive team providers in a timely and supportive manner. These successes became the basis for greater individual effort and accountability, which, in turn, generated continual quality improvement.

Furthermore, the leader capitalized on multiple opportunities to acknowledge and celebrate the accomplishments and contributions of each interdisciplinary provider in the unit. The leader carefully tracked significant occasions in the lives of staff members, recognizing birthdays, anniversaries, weddings, births, and other important events. The leader went the extra mile to welcome newcomers to the unit and to regularly thank nurses, doctors, and support staff for their valuable dedicated service.

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Servant Leadership in Action

As innovation in the workplace is examined and other more meaningful ways of attending to organizational responsibilities are explored, leaders need to reconsider the ways in which organizations function most effectively. Traditional models of hierarchical leadership, in which some people are "in control," limit the ability to capitalize on the potential of each group member. Organizations that have well-defined core values, share a common sense of purpose, provide for healthy conversation, and understand the systemic nature of their work provide a more productive model.7

Meaningful conversations translated into coordinated action require leaders who practice outside the boundaries of traditional leadership. A leader who is dedicated to enhancing the capabilities of the organization's membership and willing to embrace collective leadership can advance the image, expectations, and effectiveness of healthcare organizations. Servant leadership provides such a model.

Changes in the MICU required a considerable investment of time and energy. Results were evidenced in the short term and enhanced in the longer term through the consistent application of servant leadership principles. Leadership began by identifying underlying core values, and these were used to forge a strong commitment to the organization's essential mission of meeting the needs of the patients. Whenever disparate positions emerged, unit members were guided by their underlying mission, "to serve those who have served us." As much as possible, leadership provided nurses with the authority to make decisions in the best interest of their patients and encouraged them to explore ways to provide improved service. "This is the way we've always done it" has not been accepted as the best way to meet patients' needs. Every process was open to review and continuous quality improvement.

To facilitate organizational improvement, the unit leadership continually communicated the vision of the organization. This improved understanding contributed to a unifying team spirit, which rapidly became the hallmark of the unit.

The leader embarked on the creation of a culture that balanced proficiency with individual needs. Capitalizing on the individual talents and strengths of each member became an important focus of the nurse leader. Some employees were recognized as leaders themselves, some demonstrated extraordinary compassion, and still others were particularly dependable. Leaders provided the support and encouragement necessary to create an environment in which each employee's unique skill was acknowledged, accepted, valued, and celebrated. This commitment to growing people contributed significantly to a sense of team spirit and organizational unity.

Once this ethos was established, the goal evolved to one of "sustaining the spirit." Unit leaders often integrated several principles of servant leadership to enhance the unit's culture and ultimately the unit's effectiveness and patient satisfaction. The nurse leader combined the characteristics of intent listening with empathy, demonstrating to nurses and other staff a deep commitment to their personal and professional well-being. This practice often required extraordinary patience, allowing followers the time to find their voice and express their views, thoughts, and feelings. The eventual result was a dynamic unit within the hospital in which nurse turnover was rare and positions within the unit were highly coveted.

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Releasing the Potential in Our Organizations

Servant leadership is not without unique challenges. The application of these principles required a significant investment of leader resources. Servant leadership encourages each employee to actively seek opportunities to both serve and lead, which has the potential to significantly improve how we treat those within our institutions and the human condition in our society.8 This model relies on building competence in relationships and requires leaders to actively identify opportunities to enhance employee capabilities. Servant leadership has the power to inspire an organization to collectively be more than the sum of individual efforts. This combined capability can unleash the true potential within our organizations and, as evidenced in the MICU of the George E. Wahlen Veterans Affairs Medical Center, can create a workplace in which each member of the organization is valued and committed to personal and patient satisfaction.

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