January–March 2010
46
The importance of a servant
leader orientation
Marjorie Jenkins
Alice C. Stewart
Background: Ensuring a quality nursing workforce for the future in a time of increasing labor shortage and
declining nurse satisfaction is a key challenge to the health care industry. Understanding what impacts job
satisfaction is vital to solving the problem of nurse attrition.
Purposes: We suggest that the approach to supporting staff in the care giving role requires additional
expectations of managers who supervise inpatient nursing staff. This study empirically tested the impact of nurse
managers’ servant leadership orientation on nurse job satisfaction.
Methodology/Approach: Nurses providing direct bedside patient care within inpatient departments of a
five-hospital system were asked to respond to four questionnaires. Seventeen departments participated. There
were 346 available nurses across the departments. The average response rate was 73% across all of the units
surveyed. Hypotheses were tested using multivariate regression analysis of the nurse–nurse manager dyad.
Findings: Statistical findings of this study provided evidence that behaviors and attitudes of the nurse manager
do impact employee job satisfaction. Departments where staff perceived that managers had higher servant
leadership orientation demonstrated significant positive impact on individual employee job satisfaction.
Practice Implications: Nursing is a unique occupation in that it requires both competence in professional service
and compassion in patient caregiving. Hospitals are not factories dealing with inanimate objects or data. The
results of this research suggested that the management approach in a health care environment might be
enhanced by a more servant-oriented management approach. Specific policy changes that may be implied on the
basis of findings of this research include key areas of management selection, management development, and
management reward/evaluation.
W
ith more than 2.2 million licensed RNs in the
United States, RNs are the largest group of
professional health care workers (Bureau of
Labor Statistics, 2003). Even so, the United States is on
the precipice of a great wave of RN shortages with an
impact on health care organizations that is unprecedented (Kimball, O’Neil, & Health Workforce Solutions, 2002). By 2011, when 77 million baby boomers
turn 65, demand for nurses will have continued to
multiply against a diminishing supply. Johnson (2007)
Key words: emotional labor, job satisfaction, leader role inversion behaviors, servant leadership
Marjorie Jenkins, PhD, RN, FACHE, NEA-BC, is Director, Nursing/Magnet Program Director, Moses Cone Health System, Greensboro,
North Carolina. E-mail: marjorie.jenkins@mosescone.com.
Alice C. Stewart, PhD, is Associate Professor, School of Business and Economics, North Carolina Agricultural and Technical State University,
Greensboro. E-mail: acstewal@ncat.edu.
This research was presented at the Academy of Management, 2008, Anaheim, California, and received the ‘‘Best Theory to Practice Award’’ in
the Healthcare Division; Health Care Management Review sponsored the award.
No funding was received for this work from the National Institutes of Health, the Wellcome Trust, the Howard Hughes Medical Institute, or other
funding sources.
Receipt of approval from the North Carolina Agricultural and Technical State University institutional review board for human subjects research
was obtained for conducting this research.
Health Care Manage Rev, 2010, 35(1), 46-54
Copyright A 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
47
The Importance of a Servant Leader Orientation
recounts projections of 500,000 U.S. nursing vacancies
in 15 years.
Nurses continue to not only change jobs but also leave
the profession. By 2010, it is projected that the largest
group of working RNs will be in their 50s. This translates,
10 years later, to a significant increase in RNs in their
60s (National Advisory Council on Nurse Education and
Practice, 2008). These baby boomer nurses, perhaps delayed in their exodus from the profession because of the
economic downturn, are a part of our future nursing shortage predictions. Buerhaus, Staiger, and Auerbach (2009)
predict the shortage to reach as high as 500,000 nurses
by 2025. Other predictions, like trend watchers of the
American Hospital Association (2009), identify the shortage of nurses to become a crisis before 2025. With the
quality and efficiency of the U.S. health care system
already not what it should be (Huerta, Ford, & Brigham,
2008), the most conservative nurse shortages could cripple
our health care system. Research in the field of health care
has been examining these alarming statistics for some
time. Generally, there is agreement on some key facts: (a)
an acute nursing shortage exists and is worsening and (b) a
significant factor in the nursing shortage, particularly in
hospitals, is related to nursing dissatisfaction and burnout
(Aiken, Clarke, & Sloane, 2002). Ensuring a quality
nursing workforce for the future in a time of increasing
labor shortage and declining nurse satisfaction is a key
challenge to the health care industry. Understanding what
impacts job satisfaction is vital to solving the problem of
nurse attrition. Preventing further exodus from inpatient
settings requires nurse leaders who are proactive in strategies that revitalize the work environment, making it more
satisfying to nurses (Zangaro & Soeken, 2007).
This study examined the impact of the nurses’ perceptions of the nurse managers’ servant leadership orientation on nurse job satisfaction. Nursing is a unique
occupation in that it requires both competence in professional service and compassion in patient caregiving.
Although many service occupations exist (e.g., accounting,
customer service representatives, sales), nursing is one of
the few to have such a high expectation of personal and
relational care for the one that is served. We suggest that
this element of care requires additional expectations of
managers who supervise inpatient nursing staff. In particular, this research attempts to determine if managers
with higher servant leader orientation create more job
satisfaction among their nursing staff.
The Impact of the Nurse Manager on Nurse
Job Satisfaction
For many years, researchers have examined the importance of job satisfaction in the workplace (Drucker, 1954;
Kim, 2002). Job satisfaction is important because of its
relationship with lower turnover and increased productiv-
ity and quality of work life and is also associated with
improved organizational performance, particularly in
service-based organizations (Archibald, 2006; Shaver &
Lacey, 2003; Yaktin, Azoury, & Doumit, 2003). There is
substantial evidence to support the idea that the nurse
manager and her engagement with her staff is a key factor
in nurse job satisfaction. For nurses, job satisfaction is
multidimensional and encompasses such factors as salary/
benefits, working conditions, satisfaction with unit staffing
levels, career advancement, a voice in decision making,
and managerial support/respect (Ruggiero, 2005). Although salary and staffing levels are organizational policy
issues, many of the dimensions above (i.e., voice in decision making, managerial support, and respect) can be
directly impacted by the attitudes and behaviors of the
nurse manager. Thus, to a great extent, the nurse manager
is key to nurse job satisfaction and ultimately nurse retention (Andrews & Dziegielewski, 2005).
Managers control many factors that drive employee job
satisfaction. The Nursing Executive Center finds nurses
who are dissatisfied with their direct manager to be nearly
two times as likely to consider resignation as those satisfied
with their manager (The Advisory Board, 2000). Studies
have found that lack of recognition and lack of respect
experienced by nurses are cited as reasons for leaving
(Spence-Laschinger, 2004). Yatkin et al. (2003) found
that respect from supervisors, among other factors, is an
important determinant of job satisfaction.
Theory/Conceptual Framework
Emotional Labor as a Managerial Function
It is well established that attitudes and behaviors of nurse
managers are important to nurse job satisfaction; however,
what is it about these attitudes and behaviors that have
such an important effect? One concept that has potential to
explain the unique relationship between nurse managers
and their staff comes from work in the area of emotional
labor (Hoschschild, 1983). Emotional labor refers to the
level of emotional investment necessary to accomplish a
job. According to Hoschschild (1983), the work situation
exerts expectations (‘‘display rules’’) defining appropriate
emotional reactions of individuals involved in service
transactions. The greater the expectations of genuine care
as an aspect of the transaction, the greater the emotional
labor. Jobs may vary in their level of emotional labor, with
occupations such as nursing, child care, teaching, and other
personal service jobs described as high in emotional labor
(Bullock & Waugh, 2004). Generally, jobs high in emotional labor require not only professional competence but
also a high level of relationship and care for the client or
customer. The ability to manufacture or to generate this
level of relationship and care on demand is considered
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48
Health Care Management REVIEW
emotional labor. The organizational demand and expectation that the worker can generate this genuine emotional
investment over and over in the workplace can create stress
and burnout (Pugliesi, 1999).
Traditionally, the emotional labor component of jobs
has referred to frontline workers dealing with customers,
clients, and/or patients (Hochschild, 1983). As noted by
Harris (2002), emotional labor may not be restricted to
frontline service providers. A hypothesis worth considering is that a manager who supervises workers in jobs with
high emotional labor demands may also have an emotional
labor expectation associated with her engagement with her
staff. How managers address these expectations can either
increase or reduce emotional labor stresses on their staff.
In the case of health care, one way to siphon off some of
the emotional labor created by the care giving function
may be for nursing managers and hospital administrators to
understand that they also have an emotional labor requirement in their jobs. The emotional labor of management (or nursing supervision) is not related to patient care
as much as it is related to ‘‘worker care’’: providing the
emotional reaction and understanding needed by their
workforce during work transactions. For emotional labor to
have significant impact, the manager must consistently
support the emotional labor function of the worker by providing support, understanding, and appropriate reactions
to the emotional components of the nursing profession.
Often, this type of emotional support has been considered as an optional aspect of the managerial function
and not part of the manager/employee transaction. Although some managers may have a natural inclination to
provide emotional labor to their employees, the mechanistic orientation of most organizations has not required it.
In an industry such as health care, though, where demand
for care is skyrocketing and supply of caregivers is plummeting, providing this emotional support may be a necessary component in the retention of a nursing workforce
capable of providing the high level of care needed in a
hospital environment.
Commitment to Serve as the Basis for
Emotional Capacity
If the emotional capacity of managers is important, are
there models of managerial practice or leadership that incorporate this emotionally supportive factor? Although
most management theories underrepresent the emotional
element, some perspectives embrace the idea of an emotionally supportive manager. Robert K. Greenleaf, a scholar
of personnel and management research at AT&T and the
founder of the Center for Applied Ethics, introduced the
idea of servant leadership in a privately circulated essay,
‘‘The Servant as Leader’’ (Greenleaf, 1977). The servant
leader is different from other leaders who serve personal or
organizational goals in that she first strives to serve others
January–March 2010
and see that their needs are being met. This describes a
significant commitment to serve that represents the attitude of those that are often identified as servant leaders.
This quality of servant leadership has measurable impact on
such organizational outcomes as trust and job satisfaction.
Servant leadership may be seen to contribute to job satisfaction as a ‘‘process factor’’ (Staples & Higgins, 1998)
or as an important factor in creating a climate of care
and concern and strengthening supervisory trust (Mulki,
Jaramillo, & Locander, 2006). Servant leadership is described as relational, nurturing, other-centered, self-aware,
empathetic, and committed to the growth of individuals in
the organizational community. All of these qualities either
involve or describe the skills necessary to provide emotional labor from the manager to the worker. Without this
fundamental service attitude, a nurse manager may not
have the motivation to provide the emotional labor required of the nurses under her charge. Exercising skills
through the management function to support an emotionally overworked workforce could have a positive impact on
job satisfaction and retention. This commitment to serve,
as the basis for emotional capacity, leads to the following
hypothesis examined in this research:
Hypothesis 1: There will be a positive relationship
between a manager’s commitment to serve, as described by servant leadership, and nurse job satisfaction.
Role Inversion: Service Behaviors
that Matter
Although an attitude of service and a commitment to
serve is important, the attitude must be supported by the
actions of the nurse manager. Sherman (2002) based the
concept of role inversion behaviors on the ideas of servant
leadership described by Greenleaf (1977). Earlier measures
of servant leadership focused on attitudes. Sherman, drawing on the leader–member exchange theory, argues that a
behavioral element can effect the relationship between
the manager and the employee. Thus, Sherman expanded
the operationalization of servant leadership. Sherman’s
research explores the impact of role inversion behaviors on
job-related attitudinal and behavioral outcomes. Leader
role inversion is a comparatively uncommon, distinct style
of management in which the manager essentially inverts
the status hierarchy within the work unit. The manager
assumes a role of facilitation with subordinates assuming
the role of authority and decision maker in a particular
area of specialization. The manager partners with the staff,
deferring to their expertise to lead in solving problems in
relevant areas. One result is status enhancement for the
subordinate, and research suggests that this is a factor in
increased job satisfaction. Employee responsibility is increased and accountability shifts to a greater degree from
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49
The Importance of a Servant Leader Orientation
the manager to the nursing staff. Shifting accountability
may result in profound improvement in work-related behavior and staff attitude. This inversion is important to the
subordinate because it signals empowerment and respect.
The subordinate realizes that the manager has the formal
authority to command compliance by use of legitimate and
coercive power but instead seeks appropriate opportunities
to partner with the subordinate and chooses to serve as a
strategy of leadership. Using role inversion in this way can
have profound effect on the leader–subordinate relationship (Graen & Cashman, 1975). In the context of nursing,
role inversion could be described as allowing the nursing
professional the autonomy and role of expert with the
nurse manager acting as a facilitator of their (the nurses’)
work. The above argument leads to the following hypothesis that is examined in this research:
Hypothesis 2: There will be a significant positive
relationship between a manager’s use of role inversion behaviors and nurse job satisfaction.
Walking the Talk: The Value of Servant
Leader Orientation
The concept of servant leadership has great intuitive power
but operationally has been difficult to demonstrate. In this
research, servant leader orientation encompasses two complementary components: the service attitude unique to
servant leaders (Barbuto & Wheeler, 2006) and the behaviors that form a distinct style of leadership known as
role inversion (Sherman, 2002). The essence of servant
leader orientation must incorporate both an attitude of
commitment to serve backed up by day-to-day behaviors,
which communicate a sense of respect and dignity toward
subordinates and their professional expertise. Thus, the
strength of servant leader orientation is a function of the
interaction of commitment to serve and the extent to
which role inversion behaviors are practiced. When the
servant leader attitude of commitment to serve is consistent
with role inversion behaviors in the workplace, servant
leader orientation is the strongest. In this case, the attitudes
and the qualities associated with the servant leader construct are present, and these attributes are supported by role
inversion behaviors that create consistency between attitude and action. When commitment to serve is low and
role inversion behaviors are not practiced by the manager,
we would expect that job satisfaction among the employees
is low. The consistency of the behaviors (role inversion)
with the commitment to serve (servant leadership)
increases the level of trust between supervisor and employee. The impact of being treated as valued partner must
surely have a positive effect on the employee’s level of
satisfaction with her job. The interaction of attitude and
behavior results in the following hypothesis.
Hypothesis 3: When the manager’s commitment to
serve and role inversion behaviors are both high, servant
leader orientation of the manager will be high and will
be associated with high employee job satisfaction.
Methods
This research posits that managers with staff who are
engaged in ‘‘care intensive’’ jobs such as nursing must
also engage in supportive attitudes and behaviors characterized above by the term servant leader orientation.
The value of the servant leader orientation is that it
characterizes and represents the commitment to serve
needed to facilitate the task environment of nurses to
improve their job satisfaction.
Sample
To test the above hypotheses, this study sampled a population of nurses working for a large, multidivisional
health care system. The health care system was chosen on
the basis of researcher association and access to data, like
performance outcome indicators, that otherwise would
have been unavailable. The research was of interest to the
organization because of its relevance to internal assessment and leadership training.
The sample represented 17 of 33 departments responsible for providing direct bedside patient care within
inpatient departments. Department types included medical, surgical, telemetry, step-down, and intensive care. Each
department was led by a department head that was the focal
point of the study. All department heads reported under a
single vice president of nursing and chief nurse officer.
There were 346 available nurses within the 17 departments. All inpatient nursing departments were visited and
informed of the study. Participants were ensured confidentiality, and data were collected without identifiers. Participants were told that this process was intended to obtain
their perceptions regarding organizational leadership. Of
the available nurses, 251 agreed to participate and return
the questionnaires with 210 providing complete information on all questionnaires. The average response rate of
completed surveys across all of the units surveyed was 73%.
Data Collection
Data were collected at regularly scheduled staff meetings.
All staff are required to attend 75% of their department
meetings. For staff not in attendance at the meeting, surveys were included in a packet with directions for contacting the researcher. Participation was voluntary, and
confidentiality was guaranteed to the participants. Data
were collected via a series of questionnaires (available from
the first author). The participants were asked to complete
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50
January–March 2010
Health Care Management REVIEW
T a ble 1
Demographic characteristics of the sample
Variable
Value
n
Sample (%)
Gender
Women
Men
White
Non-White
Over 40
Under 40
192
18
159
51
86
124
91.30
8.70
75.60
24.40
41.00
59.00
Race
Age (years)
Servant Leader Orientation. Servant leader orientation is operationalized by the interaction of commitment
to serve and the role inversion behavior. When both
commitment to serve and role inversion behavior are high,
the manager will have a high servant leader orientation.
Job Satisfaction. Employee job satisfaction was operationalized as an employee’s satisfaction with their job.
Items were obtained through the work climate survey of
the Jackson Group Inc. (2007).
Measurement of the Variables
two questionnaires regarding their perceptions of their
immediate department head and one questionnaire, which
collected information on demographic characteristics.
After these questionnaires were complete, participants
were asked to complete one additional questionnaire regarding their individual job satisfaction. Table 1 shows
demographic characteristics of the sample.
Operationalization of the Constructs
Commitment to Serve. Commitment to serve is foundational to the concept of servant leadership. The desire to
serve is embedded in all conceptualizations of servant
leadership as demonstrated by Farling, Stone, and Winston,
(1999), Greenleaf (1977), Graham (1991), Polleys (2002),
and Sendjaya and Sarros (2002).
Although there is substantial conceptual research describing servant leadership, the amount and the quality of
empirical work are less well developed (Barbuto & Wheeler,
2006). Barbuto and Wheeler (2006), finding no consensus
for the empirical measurement of servant leadership in
multiple papers, proposed a starting point using the most
accepted views driving the field. Beginning with the work
of Greenleaf (1977) and Spears (1995, 2002), Barbuto and
Wheeler designed an instrument on the basis of these theorists’ major tenets. The framework included the 10 characteristics listed by Spears (1995)—listening, empathy,
healing, awareness, persuasion, conceptualization, foresight,
stewardship, commitment to the growth of people, and
building community—with the added dimension of ‘‘calling’’, which is fundamental to Greenleaf’s writings.
Role Inversion Behavior. Leader role inversion was
identified empirically by Sherman (2002) as a corollary to
leader–member exchange and is a comparatively uncommon, distinct style of leadership in which the status hierarchy is inverted. Role inversion can be measured using
Sherman’s role inversion behavior scale. Sherman’s tests for
generalizability find effects of leader role inversion to be
generalizable across multiple sites as well as occupational
categories.
Independent Variable: Commitment to Serve.
Using Barbuto and Wheeler’s (2006) 23-item survey,
commitment to serve was measured as the average across
the 23 items in the questionnaire. Each item was measured
using a 5-point Likert-type scale ranging from strongly agree
to strongly disagree. Items were summed and then divided
by 23. Scores were then converted to z-scores to compensate for restriction of range on the basis of the Likert
scale. Higher scores represent a greater commitment to
serve.
To examine the reliability of the instrument, a
Cronbach’s alpha was calculated for this 23-item survey.
The Cronbach’s alpha was .80, which is consistent with
the internal reliability of the subscales used by Barbuto and
Wheeler (2006), which ranged from .81 to .92. Barbuto
and Wheeler demonstrated the validity of their scale by
examining it relative to accepted measures of transformational leadership. Although the constructs shared some
consistent patterns, the ‘‘small effect sizes suggested that
Barbuto and Wheeler’s instrument captured somewhat
different phenomena’’ (Barbuto & Wheeler, 2006, p. 314).
Role Inversion Behavior. Role inversion behavior is
measured by summing three items on Sherman’s scale and
dividing by three to obtain an average. Each item was
measured using a 5-point Likert-type scale ranging from
strongly agree to strongly disagree. Scores were then converted to z-scores to compensate for restriction of range on
the basis of the Likert scale. Higher scores represent a
greater degree of role inversion behavior.
To examine the reliability of the instrument, a
Cronbach’s alpha was calculated for this three-item survey.
The Cronbach’s alpha was .72, which is slightly lower than
the internal reliability found by Sherman (2002) of .79.
Servant Leader Orientation. Servant leader orientation is measured by the multiplication of the commitment
to serve z-score and the role inversion behaviors z-score.
The multiplication of these two variables represents the
interaction effect.
Dependent Variable: Job Satisfaction of Nurses.
Questions are extracted from the Work Climate Survey of
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51
The Importance of a Servant Leader Orientation
the Jackson Group Inc. (2007), a nonpublished instrument
in use in health care for 18 years. The dependent variable is
measured by averaging the responses from two items where
respondents were asked their level of agreement to the
question, ‘‘Knowing what I know now, I would still make
the same decision to work here’’ and ‘‘Overall, I am
satisfied with my job here.’’ Each item was measured using
a 5-point Likert-type scale ranging from strongly agree to
strongly disagree. Scores were then converted to z-scores to
compensate for restriction of range on the basis of the
Likert scale. Higher scores represent a greater degree of
role inversion behavior.
Control Variables. At the individual level of analysis,
control variables for this study include gender, ethnicity,
and self-reported score on the individual’s most recent
performance evaluation. These control variables were included to explain variance in job satisfaction that may result
from any dissonance associated with being a non-White or
nonfemale member of the nursing profession. Performance
evaluation was included as a proxy for competence.
Findings
Data Analysis
Table 2 shows the means, the standard deviations, and the
correlation matrix for the variables used in the study. The
data from the control variables show that the sample of
nurses is primarily female and White. Job satisfaction mean
is 2.8 on a 5-point scale with standard deviation of 1.04. Job
satisfaction results indicate that many of these nurses, like
many in this profession, are not satisfied with their job.
Generally, there is a strong positive correlation between
commitment to serve and job satisfaction and role inversion behaviors and nurse job satisfaction. This relationship, between commitment to serve and job satisfaction as
well as between role inversion behaviors and job satisfaction, suggests support for Hypotheses 1 and 2. There is
a weaker but still significant inverse relationship between
servant leader orientation and job satisfaction. Commitment to serve (scale mean = 3.98, SD = .26) and role
inversion behavior (scale mean = 4.39, SD = .57) show a
correlation of .59. Because these predictor variables were
correlated, a series of tests for multicollinearity was performed to ensure that each independent and control
variable contributed independently to the variance explained in the regression models. We investigated potential
multicollinearity problems by examining variance inflation
factors and tolerance. The results of these tests were substantially below the suggested cutoffs for multiple regression models (Neter, Wasserman, & Kutner, 1985).
Table 3 shows the results of multivariate regression
analysis for the nurse–manager dyads. Model 1 includes the
control variables used in the study. Gender and diversity
results suggest that generally, without accounting for managerial impact, male nurses were more likely to report
greater job satisfaction. Performance evaluation was used as
a proxy to control for competence. There was no statistically significant relationship between performance evaluation rating and job satisfaction.
When the commitment to serve was introduced into
the model, it was positively associated with nurse job
Table 2
Means, standard deviations, and correlation matrix (N = 210)
Nurse job
Commitment Role inversion Servant leader
Performance
satisfaction to serve
behavior
orientation
Gender Ethnicity evaluation
Nurse job satisfaction 1.00
Commitment to serve
.47*
Role inversion behavior .39*
Servant leader
orientation
Gender
.11
Ethnicity
.09
Performance Evaluation .05
Mean
2.87
SD
1.04
Cronbach’s alpha
1.00
.59**
.22**
1.00
.30**
.16**
.13***
.06
3.98
0.26
.80
.14***
.16***
.10
4.39
0.57
.83
1.00
.01
.08
.06
2.81
5.70
1.00
.06
.05
1.92
0.27
1.00
.15***
4.32
1.31
1.00
3.92
1.18
*p < .001 level (two-tailed).
**p < .01 level (two-tailed).
***p < .05 level (two-tailed).
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52
January–March 2010
Health Care Management REVIEW
Table 3
Multivariate regression analysis: dependent variable = subordinate job satisfaction (N = 210)
Constant
Gender
Ethnicity
Performance evaluation
Commitment to serve
Role inversion behavior
Servant leader orientation
r2
Adjusted r2
F change
Model F-statistic
Note. Reported
Model 1
Model 2
Model 3
Model 4
3.970*
.619**
.087
.090
3.075*
.253
.019
.062
.547*
2.961*
.211
.012
.060
.468*
.146**
.051
.037**
.014
3.644**
.308
.294*
.000
22.648*
3.122*
.249
.027
.071
.432*
.133
.024**
.338
.318**
.024
17.199*
.321
.305*
.044
19.215*
coefficients are standardized.
*p < .001.
**p < .05.
satisfaction at a statistically significant level. The commitment to serve variable increased adjusted r2 of the model
substantially. This provides support for Hypothesis 1 and
also indicates the value that commitment to serve brings to
the managerial role. When nurse managers are perceived by
individual nurses as having a commitment to serve, the
nurse is likely to have greater job satisfaction.
Model 3 examines the additional impact that role inversion behavior has on job satisfaction. The value of role
inversion behavior in the model is the recognition that a
commitment to serve or the attitude of service is not the
only way to provide emotional support to the professional
caregiver. Role inversion behavior was statistically significant in the model, and the statistically significant change
in adjusted r2 justifies its additional inclusion in the model.
Role inversion behavior suggests that when nurse managers
engage in behaviors that respect the professionalism of the
nurse caregivers and provide them with empowerment, the
nurse caregivers will experience more job satisfaction. This
result occurred even with commitment to serve in the
model, thus providing support for Hypothesis 2.
Model 4 examines the idea that the interaction of commitment to serve and role inversion behavior represents the
servant leader orientation of the manager toward the individual. In this research, at the individual level of analysis,
the result was statistically significant but negatively impacting job satisfaction. The additional incremental increase in adjusted r2 was 1.3%, a statistically significant
increase. Interpretation of the sign of the standardized beta
coefficient is complex because of the use of z-scores. Ad hoc
analysis (not reported) by servant leader orientation category shows that high servant leader orientation is associated
with higher nurse job satisfaction scores; low servant leader
orientation is associated with lower nurse job satisfaction
scores. Although this result is statistically significant, the
small increase in adjusted r2 suggests that this result be interpreted with caution.
Discussion
These results suggest that role inversion behavior and
commitment to serve alone do not maximize job satisfaction. The interaction of these two dimensions—the
commitment to serve backed up by the appropriate role
inversion behaviors that support the nurse caregiver—
maximizes job satisfaction. This interaction between
commitment to serve and role inversion behaviors supports Hypothesis 3 and indicates that the emotional labor
provided by the manager to the individual can make a
difference in nurse job satisfaction.
Statistical findings of this study provide evidence that
behaviors and attitudes do impact job satisfaction. Departments where staff perceived that managers had higher
servant leadership orientation demonstrated significant
positive impact on individual employee job satisfaction.
The problems of job satisfaction and retention in the
nursing profession are difficult to solve. In this research, we
have suggested that servant leader orientation represents
the emotional labor capability needed when managing
professional care providers.
Although these findings show promise, there are limitations to this study. First, the dependent variable, job satisfaction, does not reflect the multidimensional nature of
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
53
The Importance of a Servant Leader Orientation
this concept. The measure used here was a more general
indicator of attitude toward the overall environment or
climate rather than reflecting satisfaction with particular
elements of the job. An additional limitation of the study was
that it was done within one health care system. Although
this did control for macro-organizational influences, there
could be some systemic bias that remains within the data.
Practice Implications
Implications for Practice
There are some unique occupations that require both competence in professional service and compassion in patient
care giving. Nursing is such an occupation. The emotional
labor a manager provides a nursing staff may be different
than what would be required of managers in other service
occupations like accountants or customer service representatives. Hospitals are not factories dealing with inanimate
objects or data, yet health care administrators extrapolate
management practice from theories developed from more
typically mechanistic and industrial organizations. The
results of this research suggest that the management approach in a health care environment might be enhanced by
a more servant-oriented management approach.
An interesting finding was that health care organizations are exhibiting a renewed interest in the value
of emotion in caregiving professions (Koloroutis, 2004;
Manthey, 2003). What is less well understood are the
managerial and organizational implications for creating this
within the organization. Increased expectations for caregiving cannot be met without creating a more emotionally
supportive context. Specific policy changes that may be
implied on the basis of findings of this research include key
areas of management selection, management development,
and management reward/evaluation. Emphasis on caregiving can be manifested in various organizational routines
such as hiring, professional development, and reward systems. This suggests that the responsibility of caregiving is
not just held within the individual but is also an organizational responsibility. Unless the caregiving component is institutionalized within organizational routines, the
true impact of a servant leader orientation may not yield its
maximum results.
The emphasis on creation of a supportive emotional
environment does not mean that operations and financial
performance are not are not a priority. Investments in human capital can potentially produce even greater returns
through the satisfaction and retention of employees and the
achievement of higher productivity measures. Future research should investigate the provision of emotional labor
and the opportunities for greater operational and financial
outcomes.
Conclusion
As hospitals’ largest labor expense, turnover of nursing
personnel impacts bottom-line costs and quality (Rondeau,
2008). When positions are vacant, profit margins take hits
from increased labor costs like overtime and agency payments. Hospitals are spending thousands of dollars on recruitment, but once nurses are hired, retaining them is
difficult (Gullatte & Jirasakhiran, 2005). Nurses are leaving
inpatient settings and choosing less stressful work environments (Zangaro & Soeken, 2007). Nurses dissatisfied in
their roles are leaving the profession (Lewis, 2007). At its
best, expected nurse turnover is costly (Jones, 2005). Even
under ideal circumstances, filling a position in 2 weeks
equates easily to $20,000 (direct and indirect costs) and
costs increase rapidly as the position remains unfilled (The
Advisory Board, 2007). This recruitment cycle translates to
more than $12 billion in additional industry-wide health
care costs under the best circumstances and does not take
into account the quality issues that come in to play when
replacing an experienced nurse with a new nurse.
Finding ways to enhance nurse job satisfaction is in the
best interest of health care organizations, patients, and the
nurses themselves. Reductions in costs and improvements
in care can result directly from just such an improvement.
The key to enhancing job satisfaction may be an acknowledgement that the management of professional care
providers requires an additional set of management skills.
These additional skills may require an emotional capacity
of care for the staff that is not usually part of the selection,
training, and development of nurse managers. Expectations that nurse caregivers must provide even more compassionate and relational care to patients often assumes
that care responsibility is theirs alone. The findings of this
research suggest that the care component must go beyond
the nurse caregiver and be embraced as a managerial function across the entire organization. Care of the staff through
managers who are committed to serving them and meeting
their emotional needs may be the key competitive advantage in health care in the 21st century.
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