Nursing and Leadership
Nursing is a professional occupation involving, but not limited to, giving care to patients, administering treatment and intervention strategies such as medicines, care of wounds and rehabilitation in the hospital or primary care setting. This paper aimed to determine possible applications of leadership to the nursing profession in general and in emergency level IV, especially the servant leadership theory in comparison with transactional and transformational styles of leadership. Servant leadership was found to have suitable applications on the nursing profession both in the emergency setting and in general as opposed to the other two styles which are deemed inappropriate because of their charismatic and business-like approaches. Moreover, the different principles of servant leadership were accordingly applied in day-to-day nursing practice.
Virginia A. Barrett
Texas A&M University – Corpus Christi
School of Nursing
Nursing and Leadership
Robert K. Greenleaf was an educator and writer born in 1904 in Terre Haute, Indiana. He worked at AT&T after graduating from Carleton College in Minnesota and was involved in management, development and education research. After his early retirement in 1964, he founded the Center for Applied Ethics and in 1970, published his first essay, “The Servant Leader,” where he introduced the term ‘servant leader.’ The essay was later expanded into a book in 1977 which gave birth to the Servant Leadership movement (Spears, 1998).
Greenleaf defines a servant-leader as a servant first who in becoming a leader realizes the natural aspiration to serve. After this stage, that person consciously decides to become a leader. This therefore differentiates a servant leader from a person who is leader first. Accordingly, a servant makes sure first that the peoples’ highest order of needs are being met (Greenleaf, 2002).
According to Greenleaf, the best test for assessing a leadership or an institution is through the satisfaction of the following questions: Do those being served grow as persons? Do they become more intelligent, independent, freer, healthier and more inclined to become themselves servants? What would be its benefits or effects on the least privileged (Frick, 2004)?
A servant leader should perform the following practices in order to effectively provide services and lead people towards a better and brighter prospect of growing and well-being in general:
A servant leader must learn how to listen. Listening is defined by Greenleaf as the outlook toward other people and the things that they would like to say. A servant leader must first listen to the concerns of his constituents before he can take an action toward the resolution of that particular concern. This approach naturally exposes him to possess a disposition of a servant first. In other words, a person can become a servant by learning to listen first. Listening is a healing approach which constitutes intensely paying and holding one’s attention onto the situation of the person and issues that are being raised (Spears, 1998).
A servant leader must practice ethical use of power through persuasion. Persuasion is achieved through clear explanation and dissection of every issue that is being aired followed by the setting right of things in their proper places. A state of rightness should therefore be arrived at involving one’s belief or action. However, a person should achieve this state without any element of manipulation or coercion from a servant leader. The persuaded person therefore must take that instinctive action alone without the influence of external force (Greenleaf, 2002).
When making decisions, a servant leader must seek the majority sentiment of the group. In order to express opinion on a particular subject, a servant leader must take the position or stance that would reflect the general agreement or a compromise as laid down by the group. Through this practice, a group can take the best option or decision which individuals can accept as the best one available for them. This implies that the servant leader must extensively study and understand the issue being deliberated on. The only way to go about this step is through listening. After making the decision, a servant leader must still reassess the importance of other opinions or choices that were not taken and their proponents (Frick, 2004).
A servant leader must practice foresight, which is a fundamental skill for persons aspiring to be good leaders. A leader who lacks foresight will inevitably fail in his endeavors. Greenleaf believes that it is the core ethic of leadership. Future consequences of a compromise or decision that is made today is an ethical responsibility of the leader. A servant leader must know and understand history and learn from experiences while taking enough weight on the impact and realities of the present condition to be able to predict outcomes in the future (Spears, 1998).
A servant leader must communicate to widen perspectives, not narrow them. In other words, he must be able to efficiently use language tools to impart knowledge or experience clearly without requiring the audience to take a leap towards his side. Use of appropriate language and expression can provide a connection with the speaker and listener to relay an open perspective (Greenleaf, 2002).
To be able to evaluate things based on their significance and level of attention warranted, a servant leader must learn the art of withdrawal. It involves a temporary detachment in the current state of things. It is a condition wherein the pace and dimension of all contributing factors and issues can be seen at a different angle and distance. It is a period of solitude devoid of any disturbance or influence from pressing and unnecessary matters. This offers time and space for a leader to reorient and re-organize to be able to sort out issues that must be prioritized and tackle them with balanced and unbiased approach (Frick, 2004).
Empathizing and accepting a person and his concerns enables a servant leader to become more able to offer advice or assistance. If a servant leader accepts a part and not the whole of the person being forwarded to him, the leader fails to connect and empathize with the apprehension or suffering of the person. The same is true when trying to improve or realizing the potentials of a person. A servant leader must first accept the strength and frailties of that person and empathize to the aspirations to be able to guide that person toward reaching goals and potentials (Spears, 1998).
A servant leader must be able to conceptualize. It is a principal leadership talent which requires more than good communication skills. Conceptualization involves taking significance of past, current and future perspectives to be able to construct relevant and efficient plan of action, goals and limits. Knowing such elements can help a leader analyze or predict the performance of a group and foresee challenges ahead. At the time of analysis, major points contributing to the success and failure of a concerted action can be easily reviewed (Greenleaf, 2002).
A servant leader must nurture community. A community is a person’s basic unit of involvement apart of the family. It is where a person can reach out and organize for the betterment of all constituents. It is a close interaction of people wherein if there is no liability and concern for each other, it would not exist. When enhanced, the outlook and approach of the people will spill over to other larger or higher groups such as business and government. Individuals in a community has a role but are not to be coerced to perform specific functions but must be persuaded by the servant leader for a greater and more effective involvement (Frick, 2004).
A person who realized and felt the need to serve and improve a community naturally must choose to lead. Not only will he be able to transform his surroundings but he can also serve as a fine example for other people as well who must aspire to become servant leader themselves. Everyone has the potential to lead but must first take the step in becoming a servant leader first. When a servant leader finally decides to lead, followers will naturally appear since other servant leaders are born servants (Greenleaf, 2002).
Based from the above descriptions of the basic functions of a servant leader, the following characteristics are therefore important: good listener, ability to empathize, to heal, be aware, persuade, conceptualize, gain foresight, maintain trust, and be committed to growth and community building (Spears, 1998).
Servant, Transformational and Transactional Leadership
Transformational leadership involves focus on higher level of essential needs. Transformational leaders propose an objective that transcends beyond short-term and material goals. In this theory, it is assumed that the followers will understand and identify themselves with the needs and aspirations of the leader (Bass, 1985).
Transformational leadership is characterized by its four dimensions which are charisma, inspirational motivation, intellectual stimulation and individualized attention. Charisma is also referred to as idealized influence. It is defined as the level of which the leader embody idealistic or admirable practices which would cause followers to aspire or identify with the leader. Charismatic leaders are known to express strong convictions, make a stand for principles and reach out to followers through emotional connection. This kind of leader possesses an established set of principles and values while practicing them in everyday activities so as to provide an example for followers to emulate (Burns, 1978).
Inspirational motivation is the level to which the transformational leader promotes a vision or mission that stimulates a drive or inspiration for followers. Transformational leaders use inspirational motivation in challenging followers while setting high standards, expressing the attainability of such efforts and explaining the importance of the task at hand. According to this theory, followers require a strong sense of purpose before they can be motivated to do something. This is satisfied through the provision of meaning and purpose by the leader given to a group to accomplish goals. Obviously, this requires an excellent level of communication and persuasive skills in the part of the leader to effectively relay his vision to the followers (Bass et al. 1990).
Intellectual stimulation is the capacity of the transformational leader to challenge followers with assumptions, risks and unconventional ideas to extract good or better performance. The transformational leader leaves it to the followers to maximize their potentials by reiterating strengths and possibilities. This is a form of stimulation and encouragement of the followers’ creativity by the leader (Burns, 1978).
Individualized attention is sometimes referred to as individualized consideration, which is a level to wherein the transformational leader listens to the followers’ needs and concerns. By doing so, the transformational leader aims to show his respect and appreciation to the contributions of every follower to the group or team each belongs. This highlights the individual strengths of followers that are very significant to the success of a group (Bass, 1990).
Transactional leadership on the other hand is based on the following four assumptions. First, people or followers are driven by reward and punishment. Second, organizations work efficiently with an established chain of command. Third, upon the agreement of a follower or subordinate to do a particular job they also made a deal to give all authority to the leader or manager. Fourth, the only objective of the subordinate is to do the commands of the manager (Burns, 1978). Transactional leadership is based from the establishment of a clear organizational structure, which features the chain of command, and the additional presentation of the benefits and rewards that subordinates will receive for following orders. Although punishments are seldom mentioned, they are nonetheless implied since there are existent formal procedures for discipline (Bass, 1990). Transactional leadership starts with the negotiation of a contract wherein the salary and benefits of the subordinate are listed with the clear implication of the authority of the leader or company over the subordinate (Bass, 1985).
Subordinates are held liable and responsible for the work given to them by managers. Whether they are capable or not to carry out instructions, they are expected to do them and will be punished if they fail but will also be rewarded if they succeed (Bass et al., 1990). Transactional leaders assume that if protocols and procedures are followed according to agreement, then there is nothing wrong and should not be given attention. But if performance of subordinates falls below expectation, then a corrective action is in order (Bass, 1985).
Transactional leadership is sometimes considered more as a management style and not as a form of leadership. It is especially effective in private organizations and companies. Such groups are also seen as output oriented. This is the main difference between transformational leadership, which focuses more on the followers as unique persons. There is more focus on the essential aspects of personal development towards achieving the goals of the group in transformational leadership. Transformational leadership is considered more of a selling style while transactional leadership is seen more as a telling style (Bass et al., 1990).
If transformational leadership is selling and transactional leadership is telling, then servant leadership is very much different with its unique service style. All three styles involve the motivation of followers through communication and example. All three methodologies start in the clarification of goals and potential rewards and benefits (Bass, 1985). All three stresses the importance of the contribution of each follower. However, each is unique in the mode of persuasion. Transactional leadership is pure force in obtaining results, transformational uses challenging vision and wisdom while servant leadership uses mainly performance of simple service towards the followers. Transactional leadership requires a written contract; transformational leadership requires common vision while servant leadership requires no premise but only pure initiative on the part of the servant leader. There is no agreement needed between servant leaders and other people while this is a necessity especially in transactional leadership. There is no clear cut goal in servant leadership, just an abstract notion of personal growth of all involved while transactional leadership revolves around a material product and transformational leadership reaches for the achievement for a particular vision (Bass et al., 1990).
The most important difference, however between the two leadership styles from servant leadership is the hands-on performance of activities by servant leaders as opposed to distant instruction of followers by leaders in the two former styles. This is mainly because servant leaders became servants first before becoming leaders. The accomplishment of services is a prerequisite for servant leaders before even aspiring to become leaders (Bass, 1985). Another stark difference is that servant leaders encourage followers to become leaders themselves. In transformational leadership, such idea is hard to discern if existent while in transactional leadership this is surely unacceptable since there should be a solid line that separates manager and subordinate. The only role of subordinates is to follow the instructions of managers and nothing else (Bass, 1990).
Emergency Room Nursing
The emergency room (ER) is sometimes referred to as emergency ward (EW) emergency department (ED), or accident and emergency (A&E) department. It is a hospital or primary health care section that offers preliminary treatment to patients with a wide range of disorders and injuries. Most of the cases in emergency room may be life-threatening or needing immediate intervention. Emergency departments in the modern setting are designed for rapid evaluation and management of critical conditions. People without access to health care sometimes turn to emergency departments as an entry point (Emergency Nurses Association).
A brief triage meets the patients who enter the emergency department. A triage is a protocol to determine the nature and severity of their condition. Patients with serious condition are attended by physicians immediately while patients with less serious problems are given lower priority. Based on the assessment and treatment of patients, they are either confined, stabilized, discharged or referred to another hospital. The staffs that attend patients inside an emergency department include physicians, nurses, medical and radiology technicians, assistants and volunteers (Cross & Rimmer, 2002).
Nurses in ER or ED perform duties in emergency nursing. Emergency nursing is a specialty in nursing practice wherein nurses provide care for individuals in the emergency or critical phase of their disease or injury. Nurses in this department should be capable of identifying life-threatening conditions, immediacy of care, speedily and efficiently performing resuscitative strategies and other intervention. Furthermore, they must act with a high level of independence and capacity to start needed steps without external guidance. They are also responsible for informing the patient and his relatives regarding the illness or injury as well as for providing emotional support for every news or development which may greatly affect members. Emergency nurses are the first to take care of patients with a wide range of illnesses from cancer to lesser outpatient conditions but underwent a momentary crisis or suddenly needed urgent medical attention (Emergency Nurses Association).
Emergency nursing covers the practice of initial critical care ranging from trauma-caused conditions, surgical, mental and other problems. The difference between emergency nursing from other types of nursing is the high level of knowledge and skills with the addition of analytic and decision-making authority to facilitate urgently required interventions in an independent setting or in a team effort with other health care practitioners. Emergency nurses possess a wide spectrum of skills that are generally found in other health care practitioners in different settings although they commonly diagnose and treat less critical conditions. In such cases, they also provide educational and psychosocial assessments and assistance for the recuperation of the patient (Cross & Rimmer, 2002).
Emergency nurses usually works with patients who are yet to be diagnosed, may have previously undiagnosed problems, are uninitiated to the hospital environment, are still coping with the reality of illness or injury, unclear about their condition, have chemical or behavioral complications relative to the implementation of medical intervention. They are at the front line of the dynamic interaction between the community and the health care institution. Some situations in the emergency room may be dangerous, uncontrolled and less-than-ideal. Nonetheless, emergency nurses are still required to assume supportive, informative and emphatic roles for patients and relatives alike. In addition, they are also expected to possess psychosocial and management skills related to the implementation of available community schemes and resources as deemed necessary (Emergency Nurses Association).
With the variety of roles, responsibilities, challenges and expectations of an emergency nurse, logically there should be adequate preparation and training to become one. Generally, emergency nurses have strong background related to cardiac, surgical and critical-care. Besides extensive clinical experience and knowledge, emergency nurses should also have flexible, strong interpersonal characteristics and teaching aptitude (Cross & Rimmer, 2002).
Trauma nursing is a subspecialty of emergency nursing with a narrowed-down focus on the type of patients handled. Trauma Facility Level IV is an emergency department section which offers resuscitation, stabilization, and sets up for suitable movement of major and severe trauma patients to the next trauma level facility as needed. The facility also offers continuing instruction opportunities in subjects related to trauma from health care practitioners to the community as well as implementation of injury prevention schemes. On the administrative aspect, trauma level IV facility includes the development of procedures for the assessment of trauma patient populations including intervention strategies essential for the efficient use of funding and resources (O’Shea, 2005).
Trauma nurses are licensed emergency nurses whose responsibilities include the provision of appropriate and complete medical and emotional care of injured patients and their relatives. Trauma nurses must have extensive background knowledge and expertise related to the delivery of intricate care and support needed by traumatically impaired patients including all the practices that may be necessitated in a place where a trauma patient is being treated. The settings that trauma nurses operate include pre-hospital, emergency, surgery, intensive care, peri-operative, rehabilitation and outpatient. Trauma nurses are known and perform as any of the following: nurse practitioner, prevention expert, administrative professional, researcher, bedside clinician or clinical nurse specialist (Cross & Rimmer, 2002).
Nursing and Leadership
Nurses perform multiple functions in different settings and capacities. They must deal with various personalities of patients in various stages of discomfort, pain, fear, confusion, disbelief and anger. They must also coordinate with fellow health care professionals which implies that they assume in addition the role of traffic manager inside the health care setting. Each day, they strive to provide high quality care in situations that are far from comfortable but instead exposed to unstable, uncontrolled and at times dangerous situations. To effectively satisfy these requirements of this challenging type of job, a nurse must possess appropriate skills and characters found in a good leader.
As professionals, nurses in general should have leadership skills to be able to perform in their chosen fields and to influence other people especially the patients and the general public for a more comprehensive and holistic health care service.
Although nurses in general are between the physicians and the patients, it does not mean that they can not assume leadership roles. Being in the middle can be a very good position to impart harmony in the working environment. Nurses are therefore presented an opportunity to lead in the center of the health care setting. Through teamwork, coordination and hands-on involvement with physicians and patients, nurses can take the initiative for a more harmonious path for the achievement of health care goals.
The three leadership styles can have very different effects to nursing in general. Transactional leadership cannot clearly be employed by nurses to their patients. There will never be a written contract between nurses and patients. Moreover, the impersonal style of transactional leadership is simply not applicable to nursing practice in general.
Transformational leadership can be applied to nursing in general at some level. To envision and challenge patients towards recovery might be of some help but there must also be close involvement of nurses with patients to achieve concrete results which transformational style lacks. To simply lay down abstract thoughts and show by example might not be enough for some patients struggling with pain or discomfort.
Servant leadership can be the most ideal style for nurses in general since there is delivery of service while giving a fine example of being able to stand for others and leading patients toward the resolution of their concerns or to the realization of their goals. The personal touch and involvement of servant leadership is specifically important which the other two leadership styles lack.
Emergency Nursing and Servant Leadership
Since nurses cater to the needs of patients and the public like a servant, what better leadership qualities is more appropriate than servant leadership traits? Indeed, the ten principles that constitute the theory of servant leadership appear to be the needed answers for nurses to cope with the challenges offered by emergency rooms, particularly level IV trauma (Emergency Nurses Association).
Listening. Emergency nurses are committed toward the physical and emotional relief of the multifarious concerns of patients. In order to determine the patient’s needs nurses must be able to learn to listen and intently look for signs relevant to the illness or injury. Listening enables nurses to get in touch with a patient’s inner voice to understand what the patient is really trying to communicate (O’Shea, 2005). Listening implies knowing more about the patient, family members, their living conditions, beliefs, culture, preferences, inhibitions, barriers and other equally significant information. Clearly, listening is not just the start but also the continuation in the assuming of servant leadership of nurses.
Empathy. After listening, empathy should naturally follow especially in nurses who aspire to be servant leaders. Empathy involves understanding the personality and origin of the patient. Nurses try to understand where the patients stand and what are they feeling regarding their situation. This places a more personal touch which generally characterizes the practice of nursing. Furthermore, empathy offers patients more confidence and security regarding their personal information and situation. This facilitates more open communication and shedding light on concerns previously overlooked. In essence, the nurse can establish a connection with the patient through empathy. When there is already a connection, the nurse can take a larger role in leading the patient towards recovery and personal growth during and after the intervention. Furthermore, nurse empathy as perceived by the patient’s relatives can also contribute to a smoother conduct of interventions especially those involving domestic and community settings (Cross & Rimmer, 2002).
Healing. Apart from the medical intervention towards the resolution of illnesses or recovery from injury, healing of traumatic incidents in a patient’s mind is also an important aspect. A nurse who strives to be a servant leader, can hope to deal with the health concerns of the patient through scientific methodology. Nurses, if they hope to be servant leaders, should have the innate desire not just to heal the physical aspects of a patient but also to heal and transform a disarrayed person to a more healthy and complete body and mind. Through appropriate expression of concern and empathy of the feelings of the patient regarding his health, a trauma nurse can contribute towards this transformation. Together with family members and the community, trauma level IV nurses can take the lead towards achieving each goal for each patient (O’Shea, 2005). By being servants providing the needs for healing, nurses become leaders amidst other health care professionals, patients, relatives, and the community.
Awareness. A servant leader benefits from having both general awareness and self-awareness (Greenleaf, 2002). What a nurse strives for is healing of patients and the persons surrounding them. This effort constitutes general awareness on the importance of health and well-being. To achieve awareness, nurses undertake the extraction of information, exchange of scientific facts and opinion, and continued education of patient and relatives. Self-awareness on the other hand is the realization of the strengths and potentials of a servant leader. A nurse has limitless avenues of affecting people around him/her. To attain self-awareness requires an analysis what is deep within a nurse. Without self-awareness, a nurse is incapable of understanding other people. It would also be impossible to determine the needs of other people without first identifying a nurse’s own needs. A nurse needs all information about the self to reach a conclusion about others. Complete knowledge about oneself would surely instill contentment, confidence and focus to tend to other people’s lives. Awareness is learning which is a basic step and nurses and servant leaders undergo a continuous learning process.
Persuasion. After listening, empathizing and being aware servant leaders are now in a position to take action. It may involve making a plan that requires cooperation from concerned parties. For some cases, it takes time and assurance before a direction is followed that is why a servant leader needs to be persuasive (Spears, 1998). In the case of the emergency room nurse, patient’s acceptance of his condition, cooperation with the planned intervention strategy and continued monitoring and education are all important stages of the healing process. An emergency nurse who aspires to be a servant leader, should present all the available information regarding the patient’s condition, listen to the opinion of the patient and healthcare professionals and then look for an area of consensus wherein the patient will surely benefit from. Conceptualization. The ultimate dream of a nurse is to impart the gift of healing and wholeness (Greenleaf, 2002). An emergency department is a very busy and unstable environment for emergency nurses. Despite the rigors of day to day activities, a nurse should stay focus towards achieving a bigger goal that is to serve as a leader and example as a servant leader. If a nurse should conceptualize in the context of work and fulfillment, then it would involve leaving an impact in the minds of the patients and colleagues of a way of life that is rooted in serving others. The emancipation from pain or ignorance of a patient is just a short-term objective that concerns the health of the patient. A greater endeavor is to become an example of a particular scheme which is becoming a servant leader in a health care setting.
Foresight. Servant leaders must have foresight to be able to make decisions that can withstand the effect of time and major changes. With sufficient consideration of the past, current and future implications, actions can be taken with great confidence (Frick, 2004). The same should be applicable to emergency nurses. Through experience and extensive awareness of the present realities nurses can make predictions regarding the patient’s well-being to make reassurance on the effectiveness of recommended interventions. Emergency room nurses have been exposed to countless situations that provide wisdom regarding patient concerns. Since nurses are the frontline health care professionals, they are the ones more knowledgeable on the experiences and conditions of the patients. Therefore humbly serving the basic health care needs of the patients places nurses in a higher vantage point enough to gain foresight on the situation.
Stewardship. Servant leaders are expected to be capable of maintaining the trust given to them by followers for the greater good of the society (Greenleaf, 2002). Emergency nurses are also entrusted with information and emotion from patients. They are given permission to peruse that information for the betterment of the patient. It is not just healing that is entrusted to nurses but also caring. Family and relatives open up and leave it to the nurses what are the best steps to take. In everyday emergency room conditions, nurses perform these activities dutifully. They take care of the most basic and specific needs of the patient and accompanying relatives. Medication, rehabilitation and round-the-clock monitoring are just a portion of the duties entrusted to nurses. Support, understanding and education regarding patient conditions take more than training and practice to effectively perform.
Commitment to the growth of people. If servant leaders are deeply committed for the growth of persons, nurses too have the same predisposition with focus on the health of patients. Without making an ill person well and about again, a nurse cannot hope to transform a patient to a more mature person. A nurse makes sure that the patient will have the feeling of wholeness as early as possible (Association of Emergency Nurses). By providing treatment and education, nurses contribute to the healing process and to the growth of the person. The leadership that nurses assume will be apparent in the example a servant shows to a person being served. Slowly, the patients will feel the overall changes in their outlook and the impact of such changes in their lives. In no time, nurses will have imparted essential elements of caring and serving to other people.
Community building. Servant leaders ultimately shape the community in which they live in (Spears, 1998). Nurses are also in the same situation when they become agents of healing and transformation of individuals. Individuals form a family and family forms a community. By reaching for each patient that they treat, nurses are enhancing the patient’s capacity to appreciate and eventually reciprocate good deed to other people. Each patient will then be aware of his importance in the community and should drive him to take a more significant role. Ideally, such developments should present a situation for individuals to be more liable to the position of other individuals. Being liable to the welfare of neighbors, strangers and institutions are the foundation of community building. Great concern for people around translates to concern to institutions and to the community as a whole.
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