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Servant leadership: A model for emerging nurse leaders

Fahlberg, Beth PhD, RN, CHPN; Toomey, Robert EdD

doi: 10.1097/01.NURSE.0000494644.77680.2a
Feature: NEW HORIZONS
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Leadership doesn't have to be all about power or prestige. A servant leader makes a conscious choice to lead through service to others. Find out about this new approach to leadership and how you can achieve it in your practice.

Beth Fahlberg is a faculty associate at the University of Wisconsin-Madison Division of Continuing Studies in Madison, Wis., and an adjunct faculty member at Johns Hopkins University in Baltimore, Md. Robert Toomey directs programs in leadership and management at the University of Wisconsin-Madison, Division of Continuing Studies in Madison, Wis.

The authors have disclosed no financial relationships related to this article.

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DO YOU THINK of yourself as a leader? As nurses, we learned about leadership in school, but do we recognize it in what we do on a daily basis? Do we think about becoming more effective leaders, or strategically plan how we might have influence in an area where change is needed?

Nurses are leaders. Every day, we lead, guide, direct, and advocate. We recognize where systems aren't working for our patients and where patients' needs aren't met. We say “It's not right. Someone should do something.”

Well, I'm here to challenge you: Is that “someone” you?

I've thought about, studied, observed, and reflected on leadership for many years, in many different contexts and organizations, and I want to teach you about servant leadership because this leadership model is a great fit with nursing values, roles, and responsibilities.

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Understanding servant leadership

Traditional leadership is perceived as a power grab, something an individual is driven to pursue, to obtain exclusive status and ultimate control. In contrast to this view of leadership associated with power or prestige, servant leadership comes from within. It's a response to the world around us. A servant leader is primarily driven by the desire to serve others, and then makes a conscious choice to aspire to leadership to accomplish this goal.1

Relationships are the key to successful servant leadership. Servant leaders cultivate relationships by listening, being aware and empathetic, and fostering others' growth. They also strengthen relationships by promoting collaboration and building community.

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Nurses as servant leaders

This idea of serving first and the ability to foster relationships are common characteristics of some of the best nursing leaders. We lead, speak up, volunteer, and advocate because it's the right thing to do. And it brings us to places where we can make a difference.

Many of us have become leaders, not because we want power or prestige, but because we care. We want to help. We want to make something better. We see a wrong, and we want to make it right, so we do something. Soon, others join in, becoming leaders as they learn and grow through their own service.

We see servant leadership in action when nurses get involved in:

  • initiatives around safety, quality, staffing, access to care, and palliative care
  • mentoring new nurses or nursing students
  • helping others get their work done
  • getting to know team members, and trying to understand their perspectives, background, and values, using these commonalities in negotiation and to promote teamwork.

Nurses also lead by listening to patients and families, and then advocating for them at the bedside, in the boardroom, in public discourse on social media, and in policy forums such as congressional hearings.

So how can a nurse become a servant leader? It's an ongoing process that takes time, attention, and humility. It requires nurses to reflect on their behavior, to cultivate the right attitude, and to speak and act with much more thought and care than they otherwise might. Seek out mentors and coaching opportunities. Learn to invest in others; not for any gain or glory, but because it's the right thing to do (see Five key practices for servant leaders).

In my own work, I've seen many nurses become servant leaders through their passion for palliative care. They see their patients suffering, with lots of medications and treatments, yet without adequate care for their psychosocial and spiritual needs. They see patients with heart failure dying without knowing their prognosis, and the grief of family members unprepared for the loss. They want to make things better, so the emerging servant leader steps up and starts doing something, rather than complaining or becoming disillusioned.

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Learning by example

So how do we become servant leaders? In a seminal work on the subject, Spears outlined 10 characteristics we can work on as we think about our personal journeys in becoming nursing servant leaders. See Ten characteristics of emerging servant leaders for details.

My colleague and friend Joan is a great example of a servant leader. Joan is a cardiac nurse who works in telehealth care coordination in an academic medical center. After caring for patients with heart failure for many years, she recognized that her patients had ongoing unmet needs, especially as they approached the end of their lives, and she saw that palliative care could help meet those needs. Joan listened to her patients, learned all she could, and found a group that could help: the American Association of Heart Failure Nurses Supportive & Palliative Care Community of Practice that I was leading.

Joan was excited to find a community of heart failure nurses who shared her concerns and who could support her through our social media group. With the ongoing inspiration and support of this community, she started volunteering on committees that were implementing palliative care initiatives at her hospital. This helped her connect with local palliative care leaders. Aware of her own strengths and weaknesses, she tried to find her voice in the organization. She then got involved in the Hospice and Palliative Nurses Association (HPNA), and stepped forward when they called for volunteers.

Joan isn't one to let fear get in the way of leadership. She's learned that when she leads by first serving, she grows as she helps others, who then see her as the leader she is becoming. She also knows that she doesn't have to lead alone—that she can and should ask for help. We're her community, and we've got her back.

When Joan attended the national HPNA Assembly last year, where Twitter is widely used to connect, inform, and build community, the organizers were looking for volunteers to help with the Twitter booth. Though she was new to the platform herself, she volunteered to help others learn to use Twitter. It was exciting to see how this experience built her own confidence as she invested in others' growth, helping colleagues find their voices with an important technology that can be daunting for new users. After helping an older physician send his first tweet, he told her she'd boosted his confidence immensely. She felt so rewarded.

Although it's only been few years since Joan started leading through her service, she's now being invited to teach about heart failure and palliative care in national venues. She's also coauthored several articles and a book chapter in her area of patient-care expertise. In each of these endeavors, she's led by example, representing RNs who provide direct care for patients, and become a voice that's one of the most important in healthcare today.

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Strength in numbers

Despite all that nurses can contribute to the direction of healthcare improvement, knowing so well what patients need and want, the Institute of Medicine's oft-cited Future of Nursing progress report showed that we're underrepresented in the conversations that determine the future of healthcare, and ultimately the conversations that influence what happens to our patients.2 Nurses are often underrepresented in the C-suite, where top-level administrators make decisions, although this is exactly where nurses are needed. It can be easy to find fault with the “system.” But nurses can't complain if we aren't willing to be part of the solution.

Nurses also need to be “at the table” to support policy decisions large and small. The profession of nursing is a source of strength. There are 3,129,452 professionally active RNs in the United States, as well as 834,392 LPNs and 175,021 NPs.3 That's more than 4 million nurses. In contrast, there are only 908,508 practicing physicians.3 There's strength in our numbers, especially when we join together.

We also have a remarkable professional reputation. In the most recent Gallup poll, nurses were ranked highest among all professions for honesty and ethical standards for the 14th year in a row; members of Congress were ranked much lower.4 With this in mind, it seems obvious that Congressional representatives would appreciate having nurses to advise and support them.

As we've seen with Joan, continued service has propelled her into leadership; and each time she says yes, it's opened new, exciting, and increasingly influential opportunities. I challenge you to step up, to say yes, to do something, and to grow into your full potential as a servant leader.

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Five key practices for servant leaders

Develop your vision: What do you see in the future, related to a current or anticipated need? A leader's vision inspires and motivates others to follow and to engage.

Listen and learn before speaking and acting: Be mindfully present with others, learning, assessing their concerns, values, and priorities. Have an open mind and leave all judgment and assumptions behind.

Envision and invest in others' greatness: What do you see in others? How can you help them grow? As you invest in others, they become more committed to you, becoming the new leaders in accomplishing your vision and building an effective, trusting team.

Give away your power: Allow others to have a voice, to exercise control, and to practice leading themselves, reassured by the knowledge that you have their backs.

Build community by cultivating strategic relationships: Invest in those who support the organization's values, show passion, can play to their strengths, and demonstrate a positive attitude. Provide ongoing opportunities for collaboration, sharing, reflection, encouragement, and celebration, as well as hard work.

Source: Boone LW, Makhani S. Five necessary attitudes of a servant leader. Rev Bus. 2013:83-97.

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Ten characteristics of emerging servant leaders

  1. Listening: Servant leaders are mindfully present, actively listening. They allow others to express what they want and need, clarify for deep understanding, and reflect on what they've heard.
  2. Empathy: Servant leaders strive to understand and accept others as people. They assume that people's intentions are positive, even if their behavior isn't what was expected, or what's considered appropriate.
  3. Healing: Servant leaders assess and intervene from a healing mindset to promote wholeness for others as well as for themselves.
  4. Awareness: Servant leaders recognize their own strengths, weaknesses, and values. They appreciate other peoples' different styles, preferences, values, and needs.
  5. Persuasion: Servant leaders are effective at influencing and inspiring individuals and groups to make decisions not for themselves, but for the greater good.
  6. Conceptualization: Servant leaders work to understand organizations and systems that influence the areas relevant to their leadership.
  7. Foresight: Servant leaders consider the future implications of an action, integrating lessons learned from what's happened in the past.
  8. Stewardship: Servant leaders are responsible in caring for resources of all types: human, environmental, financial, physical, material, and organizational.
  9. Commitment to others' growth: Servant leaders invest in others' growth, helping them become independent servant leaders themselves.
  10. Community builders: Servant leaders build community, creating spaces and places that invite people to work together, get to know each other, and develop a shared purpose.

Source: Spears LC. Practicing servant-leadership. Leader to Leader. 2004;(34):7-11.

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REFERENCES

1. Greenleaf RK. Servant Leadership—A Journey Into the Nature of Legitimate Power and Greatness. New York: Paulist Press; 2002.
2. Institute of Medicine. Assessing progress on the Institute of Medicine report. The Future of Nursing. Washington, DC: National Academies Press; 2016.
3. Kaiser Family Foundation. Total Number of Professionally Active Nurses and Physicians. State Health Facts. 2016. http://kff.org/state-category/providers-service-use/.
4. Gallup. Honesty/Ethics in Professions. 2015. www.gallup.com/poll/1654/honesty-ethics-professions.aspx.
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