Annals of Long Term Care

The goal of many leaders is to get people to think more highly of the leader. The goal of a great leader is to help people to think more highly of themselves.
J. Carla Nortcutt1

The competitive U.S. healthcare market today needs ethical, competent nursing leadership to ensure quality healthcare delivery to our citizens. As our population ages, the need for skilled professional nursing is expected to rise, resulting in a projected 29% shortfall of nurses by the year 2020.2 Much of this nursing care will be provided in long-term care facilities (LTCFs). Most LTCFs are already experiencing challenges with high nursing staff turnover rates.3 The problem of attracting and retaining dedicated nursing staff to work in LTC may be due to a multitude of factors such as image problems, lower wages, and voluminous regulations that micromanage and often thwart professional creativity.

Long-term care nursing has traditionally suffered from a public relations problem.4 Rather than recognizing and promoting the autonomy available to the LTC nurse, the view toward the nurse in this practice setting is associated very near the bottom rung of the glamorous professions ladder. In addition to this unmerited image issue, LTCFs in the United States are largely dependent on Medicare and Medicaid for funding, making it very difficult to financially compete with hospitals and other high-revenue settings in providing attractive nursing salaries.5

Long-term care facilities are also more heavily regulated by states and the U.S. federal government than any other type of healthcare provider.6 The regulations command volumes of paperwork, which takes nurses away from more rewarding patient-centered duties. The LTC annual survey process may be viewed as demoralizing by nursing staff, as surveyors are trained to focus on negative or “deficient” practice.

While salaries, image, and regulatory factors may not easily be changed, a significant opportunity to alter LTC nurses’ job satisfaction may lie within the power of the LTC nurse leader. The leadership style of a nurse’s immediate supervisor has been identified as a significant factor in job contentment and retention of registered nurses.7

The Servant-Leadership Model
The theoretical model of servant-leadership, as first described by Robert Greenleaf,8 will be examined here as a model for its inherent relationship to the service profession of nursing (Table). Servant-leadership goes well beyond a simple shared governance structure; it has the potential to transform culture within long-term care.

The definition of servant-leadership simply places serving of others as the number one priority.9 Greenleaf8 believed that the key difference between servant-leadership and other leadership models was found in the motivation of the leader.10 Servant-leaders are drawn to a purpose greater than themselves.11

Listening
Servant-leaders make a commitment to listen to others. The opinions and ideas of others are sought and valued. Servant-leaders are also encouraged to listen within and to seek self-understanding. Nurses in conventional LTC leadership and management positions may not have placed importance on developing this skill. Top-down organizations generally stress authoritarian decision making, accountability, and outcome-driven performance. Ideas for improvement are not traditionally solicited from direct caregiving staff. The traditional, no-questions-asked, command-and-control method of leadership leaves no room for staff to express creative ideas. Listening is also important in the face of conflict. The ability of the servant-leader to guide staff through conflict is a skill worth developing. A culture of open communication encourages participation at all levels and helps to foster emotional investments and build a culture of community.

Empathy
Greenleaf8 recognized the basic need of human beings to be viewed as individuals.