Introduction and purpose
The recent substantial increase in demand for substance abuse recovery facilities informs the urgency to study how best to lead the medical staff to effect recovery for substance abusers. Specifically, the recruiting and retention of the therapist and nursing staff and their desire to provide quality service. Further, it is necessary for therapist and nursing staff to be free to increase knowledge and leadership abilities to respond to the ever-changing needs of best practices and patients.
This study explores the option of servant leadership to achieve retention of nursing and clinical staff at Solid Landing and Silver Rock Recovery. Retention of staff requires a combination of access to information, support and benefits (Upenieks, 2002). This study reviews existing studies in order to decide if servant leadership (SL) is the best management style, and if so, how best to apply SL to Solid Landings and Silver Rock Recovery staff.
GREENLEAF’S DEFINITION OF SERVANT LEADERSHIP, HISTORY OF SERVANT LEADERSHIP AND COMMENTARY ON SERVANT LEADERSHIP
Robert Greenleaf of AT&T coined the name servant leadership. This form of leadership, during the modern era, in which leaders are focused on exhibiting integrity, encourages the idea of participation and growth for workers. This is reflected in the need humans have to bond and want to be assets within their communities. The Robert K. Greenleaf Center website defines servant leadership (SL) as:
“The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in society? Will they benefit or at least not be further deprived?” (Robert K Greenleaf Center, n.d.) (bolding, mine)
James Heskitt’s article, “Why isn’t servant leadership more prevalent?” published in Forbes, quoted Lao-Tzu (fifth-century, B.C.E.)
“The highest type of ruler is one of whose existence the people are barely aware…The Sage is self-effacing and scanty of words” (Heskitt, 2013).
Heskitt shows the essence of SL, within the beauty of a few well-chosen words, demonstrating that SL is an ancient art. Chinese philosopher Lao-Tzu, reflected above, may be the oldest example of servant leadership; next is India’s, Bhagvad Gita, and King Chandragupta Maury; then, the Greek philosopher Aristotle wrote that the teacher delivers both content and himself to a student; and for Christians, Jesus is the ultimate servant leader. Thus, the concept of servant leadership is ancient.
Northouse (2016) report on Spears’ servant leadership characteristics include:
- Listening, which is like the concept explained in multicultural class, of dialogue, defined as intense communication over time to come to a significant understanding.
- Empathy is “confirming and validating” follower’s point of view, and is how bonding occurs.
- Healing is a two-way process makes whole both the follower and leader.
- Awareness which includes situational perception, including ones impact on followers.
- Persuasion comes through example and “gentle non-judgmental argument.”
- Conceptualization refers to the meme, ‘seeing the forest through the trees,’ and as well, being able to coordinate the short and long-term goals of the organization “put first things first” (Covey, 1989).
- Foresight is the ability to predict future events based on current and past events.
- Stewardship is similar to a fiduciary relationship, which is that one that takes a higher level of responsibility (moral).
- Commitment to growth includes the concept that each individual has worth, and that staff development is an important part of management practices.
- Building community includes both inclusive and exclusive places to feel safe and to expand company ideals to the community (Northouse, 2016).
Others have expanded and revised this list to include egalitarianism, collectivism, and access, or reducing the distance between workers and management.
Heskitt, professor at Harvard Business School, asks if SL isn’t an oxymoron in today’s fast-paced, dog-eat-dog society. I argue that SL works, which can be evidenced by the companies that use it and have achieved success, including Zappos, Starbucks, Aflac, and Southwest Air. Further, the Veterans Administration (VA) Hospitals in Las Vegas and Salt Lake City have begun to utilize SL, and have experienced success.
SL takes time to establish and complete participation within the company, but the potential financial rewards related to smaller turnover are the least reason for the effort. The transformation of followers and leaders to servanthood is a multiplier of production from management and labor, and thus profits for the company.
The requirements to be a SL includes leaders who desire to be of service first, then want to lead. Servant organizations, including organizations like Sold Landings and its subsidiary Silver Rock Recovery, need supervisors and workers who are willing to accept the servant leadership ideals. These ideals include nurturing and empowering as the guiding principles for the culture and practices of the company (Northouse, 2016).
ETHICS AND LEADERSHIP SOURCES OF ORGANIZATIONAL POWER
Organizations are places of power, thus one needs to explore the sources of power as well as the applications.
To demonstrate that servant leadership’s qualities have international appeal, we first look at the Global Leadership and Organizational Behavior Effectiveness Research Project (GLOBE) study. GLOBE conducted cross-cultural studies, dividing the world into 10 distinct areas, which have similar cultures, conducted a study of 62 countries, questioning 17,000 mangers on their management views (Northouse, 2016). Although many aspects of SL were considered, they did not include SL in their results. Some of the factors in the GLOBE study are similar to servant leadership. For example, the GLOBE studied distance between the least and most powerful, humane orientation, and collectivism, which are similar to Greenleaf’s qualities which include commitment to growth (distance to power), healing (humane), and building community (collectivism) (Northouse, 2016). Therefore, the Globe characteristics are applicable, and can be a metric for many different types of organizational analysis. (The figures like the one above are available in attachments.)
Utilizing GLOBE data, Mittal and Dorfman (2012) tested the 62 different countries’ management responses, to discover how aspects of SL were applied in cultures other than Anglo, which is Greenleaf’s culture. They tested the concepts Egalitarianism, moral integrity, empowerment, empathy, and humility. Their discoveries were interesting. The highest response was to moral integrity, next egalitarianism, and empowerment. The least responses were in the aspects of empathy and humility (Mittal and Dorfman, 2012). It seems that empathy and humility are rare qualities, however, it do exist in all societies. Next, we discuss the sources of power – where and how is power viewed?
Stewart Clegg’s “Weber and Foucault: Social theory for the study of organizations” (1994) mentions that Foucault believes that “discourses are the means by which a certain power…is constituted.” Foucault wants to break from a mechanistic or sovereign view, similar to Nietzsche’s concept Kraft (force), to Macht (power), as in institutional power, such as ‘the medical gaze.’ Foucault’s powers are institutional, those that control society, such as doctors, schools, prisons, and religion, having a low level of discipline. Macht, as institutional power, must continue to be watched in order to remain Macht or, it becomes highly disciplinary, and morphing back to Kraft. Clegg also relates how Weber’s views about power agree with Marx, that ‘control’ is a vexed issue. Thus, Clegg shows that Weber, father of sociology, believed power was something besides brute force; there exists institutional power, such as a companies’ policies and procedures, or groups, such as religion.
Ted Benton’s “‘[O]bjective’ interests and the sociology of power” reviews Lukes study on power, and explains how power is tied to what he calls the ‘paradox of emancipation’ (Benton, 1981). This informs SL, as it explores the significance of determining the wants, needs, and preferences of leaders and their groups. Benton argues, that those in power cannot give emancipation to their groups, and conversely groups who are treated as autonomous are not in need or emancipation, thus his ‘paradox of emancipation.’ His analysis of the three uses of power, ignoring of emancipatory status, includes leader A, who leads from a position of autonomy from group, B.
(1) A leading according to his/her own ascribed wants, needs, and preferences without consideration of the group’s self-ascribed wants, needs and preferences.
(2) A takes into account the wants, needs, and preferences that B believes are important.
(3) A leads according to the wants, needs, and preferences that A knows are what B’s wants and needs should be, but B may not believe are their wants and needs. In this third type of power, only someone outside of both leader A and group B, would be able to determine the correct wants, needs, and preferences of both A and B.
The third idea of a leader making the ‘right decision,’ of which followers may not agree, is the crux of the problem of exerting power in an ethical manner. Can a decision/action be right, even if others believe the decision/action is wrong? This question informs the difference between servant leadership and its antecedents, transformational and charismatic leadership styles.
Our final examination of power and its use is, Karl Jung (1943) in “Psychology of the unconscious,” says, “Where love rules, there is no will to power; and where power predominates, there love is lacking. The one is the shadow of the other” (Wikiquotes 2015). Thus, as long as a leader inspires a sense of appreciation, he will have compliant followers. However, it also says, that when power is pervasive, a lack of caring or sense of ‘love’ for followers will arise.
This idea that power, even ‘servant leader’ power, can be easily put to question whether decisions made are in the best interest of followers, that love is absent in those who hold power, and thus find themselves ‘vexed,’ are reasons for the exercise of ethics. Whether power is ascribed (assumed) or assigned (given), according to Jung, respect is necessary. Benton and Clegg are cautioning the use of power, which Northouse stresses in Chapter 1: wielding power needs to be equitable and inclusive (Northouse, 2016). Therefore, love, or mutual respect, which would be Marx’s ‘vexed issue,’ and Jung’s ‘love,’ continues to be an important part of any leadership practice.
Greenleaf’s empathy and to a lesser degree, listening and awareness, listening would seem to be informed by emotional intelligence, which relates to awareness and understanding others. Barbuto, Gottfredson, and Searle (2014), examine how emotional intelligence (EI) relates to SL. They define emotional intelligence as “the ability to monitor one’s own and others’ feelings, beliefs, and internal states and use the information to guide the thinking actions of both self and others” (Barbuto et al. 2014). They found in their study, in which they believed they could relate specific SL qualities as parts of EI that when comparing leaders and followers responses, found themselves in the same situation of insignificant findings as others trying to relate EI to transformational, contingent, and exception leadership styles (Barbuto et al. 2014).
Certain EI abilities inform aspects of empathetic people. Empathy and EI are critical to those who manage and work in the medical fields, as they must be able to notice their patient’s feelings, beliefs, and internal states without extended discussion. The same applies to SL managers being able to ‘read’ their subordinates, especially to be able to notice when the employee is having problems.
UNITED STATES SERVANT LEADER STUDIES
Boone and Makhani (2012), discuss the “Five Necessary Attitudes of a Servant Leader.” Those attitudes include visioning, listening, supporting staff’s success, sharing power, and community involvement. Boone and Makhani suggest that charisma is not a valid attribute; however, attitude is, and defines a person’s ability to lead. The authors suggest that learned aspects include managing time, being proactive, empowering, ability to establish connections with others, and establishment of credibility and trustworthiness.
However, my belief is that credibility, which admits honesty and authenticity, is an attribute. Boone and Makhani suggest that credibility is the “foundation of leadership, people must believe in their leaders and know that they are worthy of trust” (Boone and Makhani 2012). Boone and Makhani (2012), mention that others have likened SL to “charismatic, transformational, as well as leader-member-exchange” leadership styles, which is interesting when considering the next study by Jill Graham.
Greenleaf’s morality concept is discussed by Jill Graham (1991). She mentions charismatic leadership is “value-neutral,” thus the inherent danger of this leadership style. It is interesting to note, that her list of charismatic leaders includes, Hitler, Jim Jones, Gandhi and Martin Luther King, two of which are notable SL leaders. Graham’s question, “what safeguards the morality of the ends and means advocated by a charismatic leader?” (Graham, 1991) deserves careful consideration. Graham reports on other’s beliefs that followers of charismatic leaders are able suspend personal responsibility in service of their leader, no matter how socially reprehensible. Therefore, it is imperative to find a charismatic leadership style with moral safeguards. Graham suggests that servant leadership’s moral imperative is the necessary addition to transformational leadership. When defining SL, Graham’s unique addition to the conversation is that SL’s are self-reflective, and thus, aware of, and avoid hubris.
Graham mentions the negative side of transformational leadership’s question, why should a follower want to change? Servant leadership answers, the change is for your (worker/follower’s) own good, rather than leader’s good; something giving workers the ability to become more valuable as they develop professionally within the company. Which is what leads back to the beginning, of Benton’s discourse on power, what controls the charismatic leader’s morality in knowing what is best for followers, even if the followers don’t agree. Thus, the urgency and centrality of the moral dimension to leadership is demonstrated. How this relates to the nursing field is the next area of literature review.
NURSING STUDIES ON SERVANT LEADERSHIP AND RETENTION
Chapter 15 in Northouse speaks to gender issues, and mentions Kanter’s organizational theory, and the stereotyping of women in the workplace (Northouse, 2016). Also, Upenieks advocates closing the distance between management and workers exchange of information. We begin a focused organizational level study on nursing, with the idea in mind of how best to recruit and retain nurses. Valda Upenieks, in “What constitutes successful nurse leadership,” (2002) utilizes Kanter’s organizational theory. Specifically, Upenieks conducted a qualitative study on 16 nurse managers from four acute care hospitals, from the aspects of support, availably of information and resources (Upenieks, 2002). Utilizing the Downe-Wamboldt method, Upenieks explored two questions:
What types of leadership traits are effective in today’s acute inpatient care environment; does power and gender interface with leadership effectiveness?
What are the predominant components of a successful organization that support the role of nurse leader? (Upenieks, 2002)
Upenieks results includes examining informal power, formal power, opportunity structure, power structure, participatory management, structure of proportion, gender socialization, central beliefs (values), business orientation, collaborative teamwork, and management support group. Upenieks reports limitation of the size and content of her study group, so recommends studying:
“qualitatively power, opportunity, control, and gender issues” with clinical nurses, and “power and gender issues with physicians … could provide a greater understanding of the intricate balance inherent in nurse-physician relationships” to create a “synergic collaborative environment for patient care” (Upenieks, 2002).
She finds that over three-quarters of the nurses surveyed “validated that access to information, opportunity, and resources in the work environment” were means to effective leadership. Further “access to these work empowerment structures created a supportive and productive climate and enhanced the success and worth” for the executive nurses (Upenieks, 2002).
Unfortunately, her subjects only responded to the structure questions; as powerful executives, they did not perceive gender as a barrier or limitation to power. They agreed that access to various forms of power, and opportunity to improve management skills “would be effective” for the mangers, but would also “empower clinical staff by sharing resources of power and opportunity, thereby enhancing nurses’ effectiveness” (Upenieks, 2002) (italics mine). These aspects are basic SL qualities, thus Upenieks organization study shows that medical organizations can adopt such concepts which would benefit their ability to retain the nursing staff.
Waterman’s (2011) feature article on the principles of servant leadership provide a clear, modern discussion on the servant aspect of this idea, and how ‘servant’ in this case is not the same as ‘chattel,’ but rather a valued part of a larger endeavor that includes community, management and workers. In this he mentions the concept of having ‘mentor mindedness,’ which means providing support where needed and sharing of skills with each other, worker, and mangers alike. Further that “a ‘servant’s heart’ does not mean offering service at all times in all situations… [but bearing service mind] when decisions are made and action are taken” (Waterman, 2011). This feature calls for a return to the concept of caring within medical services as vocation, and that this attitude needs to be both top-down and down-top, so that all share when appropriate.
Finally, we review a study by Neill and Saunders, on the Veterans Administration (VA) hospital in Salt Lake City, Utah (SLC). They explain how the deleterious situation we all have become aware of in the VA, has been turned around in SLC, partly from the decision to utilize SL within its nursing departments. They added, the change to servant leadership was time consuming and difficult, but the results were worth the effort. Neill and Saunders say, that in 2006, the facility scored high on important metrics, which was a reason to celebrate. They suggested that the reason for the change was “an emphasis on improving the quality of healthcare services and increasing professional satisfaction” (Neill and Saunders, 2008). Neill and Saunders indicate that applying the concepts of empathy and listening and creating an “interdisciplinary team approach” resulted in a renewed culture that has increased quality in patient care and greater satisfaction for professionals. Neill says, “The ultimate aim of the servant leader is to meet the highest priority need of those served” (Neill and Saunders, 2008). They conclude:
Servant leadership encourages each employee to actively seek opportunities to both serve and lead…which significantly improve how we treat those within our institutions and the human condition in our society. 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 individualized efforts…[and] can create a workplace in which each member of the organization is valued and committed to personal and patient satisfaction (Neill and Saunders, 2008).
An exchange of emails with a representative of the Las Vegas Veteran’s Administration resulted in the following response:
The last several years we’ve moved away from the medical model approach to healthcare to a holistic patient-centered, recovery model of care.
The last couple of years, we’ve had a huge push in employee ownership of the future of the VA. (Mesa, 2015)
Thus, SL is becoming more pervasive in the medical field, and is practiced by not only Zappo’s and Starbucks, two highly successful businesses, but also the VA.
The organization this qualitative study is based on is where I work part-time as the human resources clerk. The operations in Las Vegas are subsidiaries of the parent group based in Costa Mesa, California. It is a medical facility that began operations August, 2015. It has administrators, chef, dietician, physical therapist, orderlies, therapists, maintenance, housekeeping, and nurses, all working from a single facility in Las Vegas. It is supported by a laboratory division, which includes research chemists and lab assistants for Las Vegas, Texas and California operations. The organization has been in existence in California since 2009 and the Las Vegas operations including medical, lab, and administrators, received licensing and operations began August, 2015. For training purposes, the staff from doctor to orderly were hired before we had licensing. Overall there are approximately 1,200 workers company-wide, and the Las Vegas division currently employs 100 of those 1,200 workers. My focus is on hiring and retaining workers for Las Vegas, managing benefits, and coordinating with the Employee Assistance Program (EAP) representative.
This study looks specifically at the nurses, who are difficult to recruit and retain. There are two classes of nurses – nurse practitioners (ANP), who are supervised by the head nurse, but are also supervisory and can prescribe medication, and practical nurses (LPN), who are supervised by both the head nurse and the ANP’s. The company utilizes SL in a few departments, especially the lab and billing departments.
In August, four of its twelve nurses walked out, without giving notice or making any comments as to why they made this choice. I asked:
- The then-HR Generalist said, they felt some of the policies in place violated established rules and thus endanger their license.
- The General Manager said, they found positions that paid more.
- A manger in the California corporate offices, said, there is always attrition when operations begin.
The company utilizes different kinds of leadership theory in different divisions, including SL, Team, and LMX. The lab manager utilizes SL, and has had a single worker leave, even though the workload has substantially increased, and as we have yet to find additional suitable workers to reduce the workload. The nursing manager was not utilizing any discernable style. He was dismissed and one of the nurse practitioners within the remaining staff was promoted to the position. Since she was promoted, there has been substantially less turnover in the nursing department.
The billing department is only three people, the supervisor and two workers. The supervisor utilizes SL, has had no turnover, and receives complements all the time.
The other departments within the company are beyond the scope of this study. However, it is important to note the style of the executive. The General Manager said, he manages according to the needs of the worker: some workers require very little management and others significant amount of management. He uses team-type language, including “morning huddle” and “evening wrap-up,” and ‘coaches’ those who need assistance. He leaves the rest of the workers develop on their own. His is sensitive to other’s needs and exhibits humility in his communications and presentations; I believe he is a team leader and with little effort, could become a highly effective SL. Thus, the company allows different leadership styles in different departments, which follows a similar organizational theory.
The company utilizes many forms of leadership. It is clear that within the new division of Las Vegas, certain departments, specifically billing and the lab, which utilize servant leadership, and have the lowest turnover and highest level of worker satisfaction. Thus, servant leadership results in clearer recruiting criteria and less turnover. As turnover is expensive in time, money, and impact on remaining workers, it is something to be avoided.
As noted above, power within an organization is either ascribed or assigned, and as such, leaders and workers respect those who have earned the power. Power is dangerous, thus if not properly focused, through policies and procedures, and/or cultural attitudes, it can become highly damaging to a company. For example, Las Vegas is a hospitality city, with a welcoming and profitable atmosphere to business owners and tourists; but within most businesses, workers are disposable and profit is the only metric. Companies that do not implement SL will lose their employees and have high turnovers, as well as bear attendant costs. Further, without reflective managers, the chance to experience hubris is greater, which may have been the case with the nurses who left. SL provides the final level, morality, to the leadership paradigm. SL is a natural fit for this company, which provides critical services to the least of our society, which is also reflected in Greenleaf’s theory. Mentioned in this paper is the change in the SLC and Las Vegas VA hospitals. After contacting a classmate, discovered the similar policies are being instituted in the Las Vegas VA hospital as well. This means, an opportunity for a close look at how that works in a medical facility is available to us.
The companies in Las Vegas that utilize servant leadership, such as Starbucks and Zappos, have low turnover, happy employees and excellent customer service. Their recruiting methods are designed to attract workers they desire, and are highly successful. Solid Landings and Silver Rock Recovery can achieve this level of turnover and respect.
First, we would need to expand servant leadership to all departments in Las Vegas, which we would utilize as a model for future divisions and for existing divisions to study for possible adoption. The company has SL qualities within its corporate environment already, so adopting a company-wide SL program will be less traumatic than it would be for other companies. The benefits would include a more committed staff, mangers who value workers, and empower staff as the company increases access to resources and power sources, enabling the highest level of staff efficiency. Further the cachet of SL will only add a new level of respect to our already unique paradigm of services.
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