Is Servant Leadership Useful for Sustainable Nordic Health Care?

Abstract

The philosophy of servant leadership receives a growing interest in academia and among clinical health care leaders. Few European studies are available about the importance of this philosophy for patient and staff outcomes. Prior nursing studies in the US show that servant leadership is related to job satisfaction and better performance. For the purpose of investigating this among Nordic health care workers a questionnaire survey was conducted among health care staff in nursing care in four hospitals in Iceland (n=138). A new Dutch instrument (SLS) was used in an Icelandic version. The study shows that servant leadership is practiced in departments of nursing in these Icelandic hospitals and significant correlation was found between job satisfaction and servant leadership. The findings support prior findings and indicate that servant leadership among hospital managers is important for staff satisfaction. Organizational trust is foundational to servant leadership, an important element of Nordic organizational structure and among current challenges of sustainable Nordic health care services. There are reasons to continue to investigate the importance of this leadership style in Nordic health care settings and, in particular, to investigate potential links to performance and patient outcomes.

Full text

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SIGRÚN GUNNARSDÓTTIR
Introduction
Background
Servant leadership is founded on leader´s awareness, supporting beha-
vior and ethics (1) and is considered to be a philosophy of leadership
rather than a leadership style (2). Servant leadership is a relationship-
oriented leadership first introduced by Greenleaf in 1970 (3), and is
characterized as an ethical leadership philosophy with a focus on fol-
lowers (4). According to Greenleaf the optimal goal of servant lea-
dership is the well-being of the followers: “Do those served grow as
persons? Do they, while being served, become healthier, wiser, freer,
more autonomous” (3, p. 15). Recent papers have indicated the impor-
tance of servant leadership for health care services (5) and studies
have shown a link between servant leadership and positive work out-
comes for staff (6) and job satisfaction in particular (7) but further
research in this area is needed. The practice of servant leadership
includes active listening, trust in people, partnership, service and
focus on what matters most for the welfare of coworkers, clients and
society at large (1). An effective servant leader is humble, courageous
and creative and adopts various styles of leadership (2). Servant lea-
dership fosters intrinsic motivation and democratic decision making
and promotes service model as a contrast to power model (8).
Servant leadership is positively related to organizational attributes
such as justice climate and services climate as well as employee cha-
racteristics, such as job satisfaction and work engagement (9). An
interesting conceptual parallel can be identified between servant lea-
dership and Magnet hospitals model (10; 11) and organizational empo-
werment (12), both recognized as successful work environmental attri-
butes in health care services. Among these parallel attributes are prin-
ciple centered leadership, supportive behavior of leaders, access to
resources, opportunities to develop and staff participation in decision
making, all being linked to positive staff and patient outcomes (13) and
patient safety culture (14). Similarly, servant leadership has been lin-
ked to better staff outcomes in health care. Among these studies are a
correlational study with a random sample of registered nurses, nurse
managers and leaders (n=313) in a non-profit US health care organiza-
tion where a significant correlation was found between job satisfaction
and all sub-factors of servant leadership measured (15).
The literature shows that servant leadership is a significant predic-
tor of trust, e.g. as enhancing perception of trustworthiness, behavio-
ral consistency, integrity, sharing of control, responsibility, morality,
shared vision and transforming influence (16). Further down this line,
the literature shows that servant leadership may play an important role
in creating ethical culture and generating community and organizatio-
nal social capital through trust, norms, values, social cohesion, recog-
nition, obligation, shared cognition and networks (17). These organi-
zational attributes can be considered as important building blocks of
Nordic society and Nordic organizational structure. Thus, the philo-
sophy of servant leadership has the potential to provide important
insight into fundamentals of sustainable Nordic healthcare systems.
Despite increased research in health care, human resource manage-
ment, work environment, and leadership there is still urgent need to do
better, in particular, during times of restricted resources, cut down in
cost and job-dissatisfaction (18). Empirical evidence and policy
reports strongly point to the importance of new leadership styles for
the good of patient, staff and society. A recent report from the Institute
of Medicine (19) emphasizes that for the success of health care servi-
ces leaders and managers need to be involved with others as full part-
ners in a context of mutual respect and collaboration. A recent analy-
sis on current challenges in health care concludes that there are still no
convincing European models to meet the need for sustainable human
resource management in health care, however focus should be on fle-
xibility, lifelong learning, multiprofessional teamwork and involving
staff in decision making (18).
Aim
The growth in health care research on servant leadership is promising
but few European studies are available about the importance of this
philosophy for positive outcomes for patients, staff and society. There-
fore it was decided to conduct a study about the attitudes among
Nordic health care staff towards servant leadership in their work envi-
ronment and to investigate if there was a link between elements of ser-
vant leadership and better staff outcomes. These were explored by a
questionnaire survey among health care staff in nursing care in four
hospitals in Iceland. It is hypothesized that high perception of servant
leadership characteristics among nurse managers is positively related
to nursing staff job satisfaction.
Method
Participants
The study was cross-sectional and a descriptive study. Data collection
was conducted in autumn 2009 in four regional hospitals in Iceland
mainly providing elderly care. All nursing staff (n=211) working
across clinical departments in these hospitals were invited to volunta-
Is servant leadership useful for
sustainable Nordic health care?
Dr. Sigrún Gunnarsdóttir – Associate professor
Abstract
The philosophy of servant leadership receives a growing interest in academia and among clinical health care leaders. Few European
studies are available about the importance of this philosophy for patient and staff outcomes. Prior nursing studies in the US show that servant
leadership is related to job satisfaction and better performance. For the purpose of investigating this among Nordic health care workers a
questionnaire survey was conducted among health care staff in nursing care in four hospitals in Iceland (n=138). A new Dutch instrument
(SLS) was used in an Icelandic version. The study shows that servant leadership is practiced in departments of nursing in these Icelandic
hospitals and significant correlation was found between job satisfaction and servant leadership.The findings support prior findings and
indicate that servant leadership among hospital managers is important for staff satisfaction. Organizational trust is foundational to servant
leadership, an important element of Nordic organizational structure and among current challenges of sustainable Nordic health care services.
There are reasons to continue to investigate the importance of this leadership style in Nordic health care settings and, in particular, to
investigate potential links to performance and patient outcomes.
KEY WORDS:Servant leadership, nurses, job satisfaction, Nordic model
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rily complete an anonymous questionnaire survey. After two remin-
ders response rate was 65% (n=138).
Instrument
The questionnaire survey was in three parts. The first part is an Icelan-
dic version of a new Dutch instrument (Servant Leadership Survey,
SLS) about agreement of nursing staff regarding leadership behavior
of their next superior (4). The SLS instrument consists of 30 questions
on a six-point Likert scale (strongly agree – strongly disagree) relating
to the will to serve, accountability, empowerment, courage, forgi-
veness, authenticity, humility and stewardship, building on Green-
leaf´s literature about servant leaders (1). Validity and reliability of the
SLS has been published (4). The second part of the questionnaire was
a single-item question on job satisfaction about the level of satisfac-
tion with the current job on a four point Likert scale ranging from:
agree to disagree, (1 = agree and 4 = disagree). This single-item ques-
tion has previously been used and tested indicating that single items
are useful in measuring job satisfaction as a global construct (13). The
third part covered demographic characteristics including age, years of
experience in current job, managerial work, occupation (nurse, nurse
aid, other) and work-time proportion. The study was approved in
advance by relevant hospitals and the study was also reported to the
Icelandic Data Protection Commission (S4486/2009).
Data analysis
Survey data was analyzed using SPSS (17.0). Descriptive analysis of the
study data was performed and reliability analysis using Cronbach´s
Alpha (α) on SLS sub-scales were calculated. Correlation analysis was
used to investigate relationships between servant leadership factors, job
satisfaction and background variables.Variation between groups in rela-
tion to demographics of participants was explored using Tukey HSD
test. Significance were set at the level of p<0.01 (2-tailed) (20).
Findings
The number of useable returned questionnaires were 138. Nurses were
60% (n=83) of participants, nurse aids 33% (n=46) and 18% had a
managerial job. Majority of participants (75%) were 40 years or older,
41% had worked longer than 15 years in current job, majority (62%)
worked more than 75% of fulltime jobs.
The findings of the study indicate that the Icelandic version of the
SLS is reliable (Cronbach´s Alpha 0,891 – 0,926). Descriptive statistics
for the SLS factors are summarized in table 1 with mean values and
standard deviations and shows that perceived servant leadership (range
1-6) measured moderately high (mean 3,99 – 4,99) indicating that ser-
vant leadership is practiced in nursing care management in these hospi-
tals according to the views of the respondents in the present study and as
compared to findings on the SLS scales in previous studies (4).
Significant difference between groups (demographics and staff
groups) in relation to SLS factors means was found only in relation to
age, i.e. perception of servant leadership was lowest (3,66) among the
youngest age group (20-29 years; SD: 0,675).
The results show that the majority (97,8%) of the respondents are
satisfied with their jobs (very satisfied (39,4%) and moderately satis-
fied (58,4%)). Only 0,7% were very dissatisfied and 1,5% a little dis-
satisfied. No significant difference was found between demographic
and staff groups. Bivariate (Pearson) intercorrelation between job
satisfaction and perception of servant leadership characteristics shows
a significant correlation (p<0,01) in relation to all factors of servant
leadership except servitude (table 2). SLS factors most strongly rela-
ted to nursing staff job satisfaction were factors on humility, empower-
ment, accountability and authenticity as characteristics corresponding
to servant leadership.
Discussion
The findings of this study support prior f indings about the significant
correlation between servant leadership and job satisfaction as presen-
ted in a Dutch multi-site study based on the same instrument (4) and
in recent health care studies based on other servant leadership instru-
ments (7, 15). Present findings further strengthen the evidence about
the importance of servant leadership among hospital managers for job
satisfaction of health care staff.
Empowerment, humility and accountability
The study supports a link between job satisfaction and leadership
empowering behavior. This emphasizes how important it is for health
care leaders to encourage their staff, enable them to have access to
information and resources, and to have open channels to learn, deve-
lop and to participate in decision making (4, 13, 14). Interestingly, this
study also supports that humility is an important leadership characte-
ristic, corresponding to the leader´s awareness of his or her own
strength and weakness and thus in an attempt to balance own limitati-
ons seeks ideas and input from coworkers in a partnership based on
mutual respect and the will to serve (1, 4). Furthermore, this study
supports the meaning leaders´ accountability and trust for effective
leadership (4, 16). This underpins the usefulness of holding staff
responsible for their work and performance as well as taking care of
them in a fair and just manner (17). Given this, empowering work
environment, trust, humility, and fairness among health care leaders
may be considered important elements in building sustainable health
care services.
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VÅRD I NORDEN 2/2014. PUBL. NO. 112 VOL. 34 PP 53–55
Table 1. Nursing staff perception of servant leadership
characteristics (n=138). Cronbach´s alpha and mean of total
SLS score among and SLS sub-factors. SLS range 1 – 6.
Cronbach´s alpha Mean (SD)
SLS-sub factors:
Empowerment 0,891 4, 74 (0,77)
Servitude 0,907 4, 99 (0,62)
Accountability 0,901 4, 99 (0,62)
Forgiveness 0,923 4, 81 (0,85)
Courage 0,926 3,99 (1,04)
Authenticity 0,892 4, 33 (0,79)
Humility 0,894 4, 57 (0,74)
Stewardship 0,896 4, 99 (0,81)
Total Score SLS 0,887 4,65 (0,61)
Table 2. Bivariate (Pearson) intercorrelations between nursing
staff satisfaction with present job and servant leadership
characteristics; SLS sub-factors and total SLS score.
Job satisfaction
SLS-sub factors:
Empowerment 0,478*
Servitude 0,279
Accountability 0,445*
Forgiveness 0,279*
Courage 0.298*
Authenticity 0,406*
Humility 0,479*
Stewardship 0,392*
Total Score SLS 0,584*
*p< 0,01
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Sustainability and leadership
Present study supports and further contributes to current evidence on
healthy work environment in health care for staff and patients (21).
The study sheds light on how the philosophy and practice of servant
leadership can strengthen the foundation of success and enable sustai-
nability of current health care services. In particular this is interesting
for the Nordic countries as it is reasonable to believe that key elements
of servant leadership have similarities to important characteristics of
social capital (17) and a Nordic style of leading and managing (22).
Organizational trust, humility and partnership are foundational to ser-
vant leadership and are as well among current challenges of sustai-
nable Nordic health care services. In summary this study indicates
how trust, partnership and supportive leadership of a servant leader
can reinforce trust, social cohesion and shared goals and thus social
capital in a health care for the good of patients, staff and society.
Conclusion and practical implications
Patient safety and staff dissatisfaction continues to be of major concern
with consequent risk for the sustainability of health care. This study
supports the importance of servant leadership for sustainable health
care services with focus on trust, partnership and supportive leaders-
hip. These leadership characteristics have the potential to reinforce
trust, social cohesion, shared goals and social capital. This may provide
and interesting and valuable strategy for leaders in the context of chal-
lenging environment of current health care services. In particular, the
philosophy of servant leadership may prove meaningful for sustainable
Nordic health care services grounded on democratic values and cul-
ture, the cornerstones of the Nordic welfare society. Figure 1 shows a
proposed model of sustainable Nordic health care services inspired by
philosophy of servant leadership and social capital. It is important to
continue to investigate the relevance and effectiveness of this leaders-
hip style in Nordic health care settings and, in particular, to further
investigate potential links to performance and better patient outcomes.
The literature suggests that servant leaders take their roles and respon-
sibilities seriously but they do not take themselves very seriously. The
question remains if Nordic health care leaders are ready to invest in a
model where the focus is primarily on the needs of patients and staff
and they themselves are first among equals?
Acknowledgement
Erla Björk Sverrisdóttir, MSN, gathered survey data and conducted
the initial data analyses.
Accepted for publication 30.05.201
Dr. Sigrún Gunnarsdóttir – Associate professor, Faculty of Nursing,
University of Iceland, Eiríksgata 34, IS – 101 Reykjavík;
Tel: 354 525 4919; sigrungu@hi.is
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SIGRÚN GUNNARSDÓTTIR
Figure 1. Proposed model of sustainable Nordic health care
services inspired by philosophy of servant leadership and
social capital.
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