One of the greatest challenges facing anyone working in critical care is leadership. No matter who we are, we are at times put into circumstances that require us to flex our “leadership muscle.” Some of you might think leadership issues don’t directly impact you. However, we believe that leadership skills can help all of us regardless of role. Whether one is a charge nurse for the day, a nurse manager in an intensive care unit (ICU), or a bedside nurse involved in a code situation, having leadership skills is always valuable. In this editorial we’ll focus on a particular style of leadership that we feel is particularly worthwhile: servant leadership.
What do we mean by servant leadership? To understand the concept, perhaps it’s best to divide the construct into premodern and modern. Premodern concepts of servant leadership stretch all the way back to ancient Chinese writings and early Christianity, during which time it was believed that “to be a leader, one must be a servant first.”1–3 The modern concept of servant leadership, which is more germane to this discussion, was developed by Robert K. Greenleaf in 1970.4,5 Greenleaf spent his career working at AT&T as their head of management research. With respect to servant leadership, Greenleaf wrote:
The servant-leader is servant first…. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first, perhaps because of the need to assuage an unusual power drive or to acquire material possessions…. The leader-first and the servant-first are 2 extreme types. Between them there are shadings and blends that are part of the infinite variety of human nature.
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?1–3
One of the key differences between standard autocratic leadership and servant leadership is that the latter is a bottom-up approach, whereas the former is more top-down. Of course, the classic style of leadership is that someone high up in a business structure makes the decisions and the people below simply follow them. In a servant leadership structure, this approach is inverted, with the primary job of the leaders being to foster, nurture, and nourish the associates in an organization so they can be the best they can be. Not only are the voices of the associates heard, but their ideas are communicated, disseminated, and implemented much more easily to those in positions of leadership.
Whom Do We Serve?
“Whom do we serve?” Perhaps this is the most important question we can ask when thinking about servant leadership in the critical care setting. First and foremost, we are all here to serve the patient. Serving patients is our primary focus and the idea behind patient-centered care. Although such a thing may seem obvious, it cannot be overemphasized, and it is equally important to ask why. That is, why do we serve? In clinical practice perhaps the “why” is obvious and straightforward. We come to work each day to be part of a team that provides the highest possible level of care to each and every patient we encounter.
Nevertheless, we may not be able to practice to our full potential on any given day. Perhaps we are having personal problems. Perhaps the unit is understaffed. Perhaps there is some piece of equipment missing. We have all been through these kinds of situations. This is where a servant leadership approach might be valuable. For servant leaders, the focus would be that we must serve the patient, and that as members of the team we are here to serve one another. Working together, we all win.
Putting Others First
Let’s use the example of a lead intensivist or medical director of an ICU. As a servant leader, this person serves many groups. Serving the patients is the first priority, of course. Whereas it should go without saying, doing what is best for the patient is the primary focus for every member of the organization. Next, the medical director is a servant to his or her fellow physicians in the group. The focus here is to foster and nurture the junior physicians to make sure they are progressing properly in their career. It is about figuring out what is best for each member of the team and how to ensure that each person feels that her or his job is meaningful.
The medical director might serve several other groups: bedside nurses, the nurse administrator of the unit or units he or she helps supervise, the senior nursing leadership of the hospital, and so on. The medical director also serves the physicians who admit patients to their unit, the chairs of the various departments, and the senior administrators for the entire organization. This kind of approach can be applied to any member of the interprofessional team. One begins at the beginning with serving the patient, then branches out to determine which other groups must be served as well.
Finding Strengths and Weaknesses
One important characteristic of servant leaders is their ability to work closely with colleagues to find their strengths and weaknesses. Such work is important because one usually can find positions within an organization where the areas of strengths are emphasized and the areas of weakness are deemphasized. For example, a nurse may be assigned to a particular ICU where he or she is required to work closely with surgeons, and might not like it, whereas the same nurse might thrive in a more medical environment. Perhaps a nurse is starting to show signs of interest in a particular subspecialty area, or is begining to demonstrate interest in administrative or teaching areas.
As servant leaders, we are always engaging with members of our team to ensure they are working in positions that are the best possible fit for their global strengths and weaknesses. Taking a little extra time to make these efforts can lead to greater employee retention, greater productivity, and a more positive work experience overall—with a better patient experience as the ultimate outcome.
Humility can be defined as neither overestimating one’s merits nor overvaluing oneself. From a servant leadership perspective, humility is consistent with a healthy ego and is not a sign of weakness. The issue here is to reconcile a leadership position with the concept of not necessarily knowing, understanding, or having all the answers. Again, a true servant leader is determined to remain modest, calm, and focused on giving credit to others. In other words, a great servant leader creates an environment where the people in the organization want to “give it their all,” and by extension the organization does well.
Challenges to Implementation
We would be remiss if we did not mention some of the challenges to implementation of a servant leadership culture in an organization. First of all, most medical centers and medical schools are still organized into department silos, each with its own leaders. Leaders of those departments must take the initiative to focus on servant leadership. Second, some may be uncomfortable with the servant leadership model, preferring the more traditional autocratic style. Regardless, we feel that servant leadership specifically and explicitly fits well with the overall goals of critical care nursing and medicine: never take your eye off the ball; that is, the patient comes first. Many obstacles to servant leadership must be overcome so our teams can be the best they can be.
As we reflect more deeply about this approach to leadership, perhaps we realize that it is more than just a leadership style, but a philosophy of life. Servant leadership permits us to demonstrate leadership without requiring the spotlight. It is a leadership style in which the emphasis is on leading while being unassuming: an opportunity to lead and let others take the credit. Servant leadership stresses the importance of aspirations for the organization rather than ambitions for a particular person: humility, collaboration, and a meaningful work experience lead to positive results. What is exciting about servant leadership is that it allows people who may not have a classic leadership personality (eg, outgoing, take-charge, seeking the spotlight) to step forward and say, “I would like to help here.” It allows all of us to see that there is a style of leadership whereby leaders are there to support the organization and support us.
There is much to read about servant leadership, and so we have included additional references.6–13 With this editorial we hope to have stimulated some thought and encouraged further dialogue on the topic of servant leadership. We wish for readers to consider the merits of this philosophy in themselves and in the leadership structure of their organizations. This deceptively simple but powerful approach to leadership can lead both to excellent results for our organizations and to profound meaning in the lives of those it touches.
The statements and opinions contained in this editorial are solely those of the coeditors in chief.
Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Submit a response” in either the full-text or PDF view of the article.
To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, firstname.lastname@example.org.