Editorial Analysis: Servant Leadership and Critical Care Management
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This report analyzes an editorial from the American Journal of Critical Care (AJCC) focusing on servant leadership, authored by Richard H. Savel and Cindy L. Munro. The editorial defines servant leadership, contrasting it with traditional autocratic models, and emphasizes the leader's role in serving ot...
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SERVANT LEADERSHIP:
THE PRIMACY OF SERVICE
By Richard H. Savel,MD, and Cindy L. Munro,RN, PhD, ANP
Editorial
One of the greatest challenges facing anyone
working in critical care is leadership. No
matter who we are, we are at times put into
circumstances that require us to flex our “leadership
muscle.” Some of you might think leadership issues
don’t directly impact you. However, we believe that
leadership skills can help all of us regardless of role.
Whether one is a charge nurse for the day, a nurse
manager in an intensive care unit (ICU), or a bed-
side nurse involved in a code situation, having lead-
ership skills is always valuable. In this editorial we’ll
focus on a particular style of leadership that we feel
is particularly worthwhile: servant leadership.
Background
What do we mean by servant leadership? To
understand the concept, perhaps it’s best to divide
the construct into premodern and modern. Premod-
ern concepts of servant leadership stretch all the way
back to ancient Chinese writings and early Christian-
ity, during which time it was believed that “to be a
leader, one must be a servant first.”1-3 The modern
concept of servant leadership, which is more ger-
mane to this discussion, was developed by Robert K.
Greenleaf in 1970.4,5 Greenleaf spent his career work-
ing at AT&T as their head of management research.
With respect to servant leadership, Greenleaf wrote:
The servant-leader is servant first.... It begins
with the natural feeling that one wants to serve,
to serve first. Then conscious choice brings one
to aspire to lead. That person is sharply different
from one who is leader first, perhaps because of
the need to assuage an unusual power drive or to
acquire material possessions.... The leader-first
and the servant-first are 2 extreme types. Between
them there are shadings and blends that are
part of the infinite variety of human nature.
The difference manifests itself in the care taken
by the servant-first to make sure that other peo-
ple’s highest priority needs are being served. The
best test, and difficult to administer, is: Do those
served grow as persons? Do they, while being
served, become healthier, wiser, freer, more
autonomous, more likely themselves to become
servants? And, what is the effect on the least priv-
ileged in society? Will they benefit or at least not
be further deprived?1-3
One of the key differences between standard
autocratic leadership and servant leadership is that
the latter is a bottom-up approach, whereas the for-
mer is more top-down. Of course, the classic style of
leadership is that someone high up in a business
structure makes the decisions and the people below
simply follow them. In a servant leadership struc-
ture, this approach is inverted, with the primary job
of the leaders being to foster, nurture, and nourish
the associates in an organization so they can be the
©2017 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2017356
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 97
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
THE PRIMACY OF SERVICE
By Richard H. Savel,MD, and Cindy L. Munro,RN, PhD, ANP
Editorial
One of the greatest challenges facing anyone
working in critical care is leadership. No
matter who we are, we are at times put into
circumstances that require us to flex our “leadership
muscle.” Some of you might think leadership issues
don’t directly impact you. However, we believe that
leadership skills can help all of us regardless of role.
Whether one is a charge nurse for the day, a nurse
manager in an intensive care unit (ICU), or a bed-
side nurse involved in a code situation, having lead-
ership skills is always valuable. In this editorial we’ll
focus on a particular style of leadership that we feel
is particularly worthwhile: servant leadership.
Background
What do we mean by servant leadership? To
understand the concept, perhaps it’s best to divide
the construct into premodern and modern. Premod-
ern concepts of servant leadership stretch all the way
back to ancient Chinese writings and early Christian-
ity, during which time it was believed that “to be a
leader, one must be a servant first.”1-3 The modern
concept of servant leadership, which is more ger-
mane to this discussion, was developed by Robert K.
Greenleaf in 1970.4,5 Greenleaf spent his career work-
ing at AT&T as their head of management research.
With respect to servant leadership, Greenleaf wrote:
The servant-leader is servant first.... It begins
with the natural feeling that one wants to serve,
to serve first. Then conscious choice brings one
to aspire to lead. That person is sharply different
from one who is leader first, perhaps because of
the need to assuage an unusual power drive or to
acquire material possessions.... The leader-first
and the servant-first are 2 extreme types. Between
them there are shadings and blends that are
part of the infinite variety of human nature.
The difference manifests itself in the care taken
by the servant-first to make sure that other peo-
ple’s highest priority needs are being served. The
best test, and difficult to administer, is: Do those
served grow as persons? Do they, while being
served, become healthier, wiser, freer, more
autonomous, more likely themselves to become
servants? And, what is the effect on the least priv-
ileged in society? Will they benefit or at least not
be further deprived?1-3
One of the key differences between standard
autocratic leadership and servant leadership is that
the latter is a bottom-up approach, whereas the for-
mer is more top-down. Of course, the classic style of
leadership is that someone high up in a business
structure makes the decisions and the people below
simply follow them. In a servant leadership struc-
ture, this approach is inverted, with the primary job
of the leaders being to foster, nurture, and nourish
the associates in an organization so they can be the
©2017 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2017356
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 97
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
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best they can be. Not only are the voices of the asso-
ciates heard, but their ideas are communicated,
disseminated, and implemented much more eas-
ily to those in positions of leadership.
Whom Do We Serve?
“Whom do we serve?” Perhaps this is the most
important question we can ask when thinking
about servant leadership in the critical care setting.
First and foremost, we are all here to serve the
patient. Serving patients is our primary focus and
the idea behind patient-centered care. Although
such a thing may seem obvious, it cannot be over-
emphasized, and it is equally important to ask
why. That is, why do we serve? In clinical practice
perhaps the “why” is obvious and straightforward.
We come to work each day to be part of a team that
provides the highest possible level of care to each
and every patient we encounter.
Nevertheless, we may not be able to practice to
our full potential on any given day. Perhaps we are
having personal problems. Perhaps the unit is
understaffed. Perhaps there is some piece of equip-
ment missing. We have all been through these
kinds of situations. This is where a servant leader-
ship approach might be valuable. For servant leaders,
the focus would be that we must serve the patient,
and that as members of the team we are here to
serve one another. Working together, we all win.
Putting Others First
Let’s use the example of a lead intensivist or
medical director of an ICU. As a servant leader, this
person serves many groups. Serving the patients is
the first priority, of course. Whereas it should go
without saying, doing what is best for the patient is
the primary focus for every member of the organiza-
tion. Next, the medical director is a servant to his or
her fellow physicians in the group. The focus here
is to foster and nurture the junior physicians to
make sure they are progressing properly in their
career. It is about figuring out what is best for each
member of the team and how to ensure that each
person feels that her or his job is meaningful.
The medical director might serve several other
groups: bedside nurses, the nurse administrator of
the unit or units he or she helps supervise, the
senior nursing leadership of the hospital, and so on.
The medical director also serves the physicians who
admit patients to their unit, the chairs of the vari-
ous departments, and the senior administrators for
the entire organization. This kind of approach can
be applied to any member of the interprofessional
team. One begins at the beginning with serving the
patient, then branches out to determine which other
groups must be served as well.
Finding Strengths and Weaknesses
One important characteristic of servant leaders
is their ability to work closely with colleagues to
find their strengths and weaknesses. Such work is
important because one usually can find positions
within an organization where the areas of strengths
are emphasized and the areas of weakness are
deemphasized. For example, a nurse may be
assigned to a particular ICU where he or she is
required to work closely with surgeons, and might
not like it, whereas the same nurse might thrive in
a more medical environment. Perhaps a nurse is
starting to show signs of interest in a particular sub-
specialty area, or is begining to demonstrate interest
in administrative or teaching areas.
As servant leaders, we are always engaging with
members of our team to ensure they are working in
positions that are the best possible fit for their
global strengths and weaknesses. Taking a little extra
time to make these efforts can lead to greater
employee retention, greater productivity, and a
more positive work experience overall—with a bet-
ter patient experience as the ultimate outcome.
Practicing Humility
Humility can be defined as neither overesti-
mating one’s merits nor overvaluing oneself. From a
servant leadership perspective, humility is consistent
with a healthy ego and is not a sign of weakness. The
issue here is to reconcile a leadership position with
the concept of not necessarily knowing, under-
standing, or having all the answers. Again, a true
servant leader is determined to remain modest,
calm, and focused on giving credit to others. In
About the Authors
Richard H. Savel is coeditor in chief of the American
Journal of Critical Care. He is director, Adult Critical Care
Services, at Maimonides Medical Center and a professor
of clinical medicine at the Albert Einstein College of Med-
icine, both in New York City. Cindy L. Munro is coeditor in
chief of the American Journal of Critical Care. She is asso-
ciate dean for research and innovation at the University
of South Florida, College of Nursing, Tampa, Florida.
First and foremost, we are all here to
serve the patient.
98 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 www.ajcconline.org
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
ciates heard, but their ideas are communicated,
disseminated, and implemented much more eas-
ily to those in positions of leadership.
Whom Do We Serve?
“Whom do we serve?” Perhaps this is the most
important question we can ask when thinking
about servant leadership in the critical care setting.
First and foremost, we are all here to serve the
patient. Serving patients is our primary focus and
the idea behind patient-centered care. Although
such a thing may seem obvious, it cannot be over-
emphasized, and it is equally important to ask
why. That is, why do we serve? In clinical practice
perhaps the “why” is obvious and straightforward.
We come to work each day to be part of a team that
provides the highest possible level of care to each
and every patient we encounter.
Nevertheless, we may not be able to practice to
our full potential on any given day. Perhaps we are
having personal problems. Perhaps the unit is
understaffed. Perhaps there is some piece of equip-
ment missing. We have all been through these
kinds of situations. This is where a servant leader-
ship approach might be valuable. For servant leaders,
the focus would be that we must serve the patient,
and that as members of the team we are here to
serve one another. Working together, we all win.
Putting Others First
Let’s use the example of a lead intensivist or
medical director of an ICU. As a servant leader, this
person serves many groups. Serving the patients is
the first priority, of course. Whereas it should go
without saying, doing what is best for the patient is
the primary focus for every member of the organiza-
tion. Next, the medical director is a servant to his or
her fellow physicians in the group. The focus here
is to foster and nurture the junior physicians to
make sure they are progressing properly in their
career. It is about figuring out what is best for each
member of the team and how to ensure that each
person feels that her or his job is meaningful.
The medical director might serve several other
groups: bedside nurses, the nurse administrator of
the unit or units he or she helps supervise, the
senior nursing leadership of the hospital, and so on.
The medical director also serves the physicians who
admit patients to their unit, the chairs of the vari-
ous departments, and the senior administrators for
the entire organization. This kind of approach can
be applied to any member of the interprofessional
team. One begins at the beginning with serving the
patient, then branches out to determine which other
groups must be served as well.
Finding Strengths and Weaknesses
One important characteristic of servant leaders
is their ability to work closely with colleagues to
find their strengths and weaknesses. Such work is
important because one usually can find positions
within an organization where the areas of strengths
are emphasized and the areas of weakness are
deemphasized. For example, a nurse may be
assigned to a particular ICU where he or she is
required to work closely with surgeons, and might
not like it, whereas the same nurse might thrive in
a more medical environment. Perhaps a nurse is
starting to show signs of interest in a particular sub-
specialty area, or is begining to demonstrate interest
in administrative or teaching areas.
As servant leaders, we are always engaging with
members of our team to ensure they are working in
positions that are the best possible fit for their
global strengths and weaknesses. Taking a little extra
time to make these efforts can lead to greater
employee retention, greater productivity, and a
more positive work experience overall—with a bet-
ter patient experience as the ultimate outcome.
Practicing Humility
Humility can be defined as neither overesti-
mating one’s merits nor overvaluing oneself. From a
servant leadership perspective, humility is consistent
with a healthy ego and is not a sign of weakness. The
issue here is to reconcile a leadership position with
the concept of not necessarily knowing, under-
standing, or having all the answers. Again, a true
servant leader is determined to remain modest,
calm, and focused on giving credit to others. In
About the Authors
Richard H. Savel is coeditor in chief of the American
Journal of Critical Care. He is director, Adult Critical Care
Services, at Maimonides Medical Center and a professor
of clinical medicine at the Albert Einstein College of Med-
icine, both in New York City. Cindy L. Munro is coeditor in
chief of the American Journal of Critical Care. She is asso-
ciate dean for research and innovation at the University
of South Florida, College of Nursing, Tampa, Florida.
First and foremost, we are all here to
serve the patient.
98 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 www.ajcconline.org
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
other words, a great servant leader creates an envi-
ronment where the people in the organization want
to “give it their all,” and by extension the organiza-
tion does well.
Challenges to Implementation
We would be remiss if we did not mention
some of the challenges to implementation of a ser-
vant leadership culture in an organization. First of
all, most medical centers and medical schools are
still organized into department silos, each with its
own leaders. Leaders of those departments must
take the initiative to focus on servant leadership.
Second, some may be uncomfortable with the ser-
vant leadership model, preferring the more tradi-
tional autocratic style. Regardless, we feel that
servant leadership specifically and explicitly fits well
with the overall goals of critical care nursing and
medicine: never take your eye off the ball; that is,
the patient comes first. Many obstacles to servant
leadership must be overcome so our teams can be
the best they can be.
Conclusions
As we reflect more deeply about this approach
to leadership, perhaps we realize that it is more
than just a leadership style, but a philosophy of life.
Servant leadership permits us to demonstrate lead-
ership without requiring the spotlight. It is a leader-
ship style in which the emphasis is on leading while
being unassuming: an opportunity to lead and let
others take the credit. Servant leadership stresses the
importance of aspirations for the organization
rather than ambitions for a particular person:
humility, collaboration, and a meaningful work
experience lead to positive results. What is exciting
about servant leadership is that it allows people
who may not have a classic leadership personality
(eg, outgoing, take-charge, seeking the spotlight) to
step forward and say, “I would like to help here.” It
allows all of us to see that there is a style of leader-
ship whereby leaders are there to support the orga-
nization and support us.
There is much to read about servant leadership,
and so we have included additional references.6-13
With this editorial we hope to have stimulated some
thought and encouraged further dialogue on the
topic of servant leadership. We wish for readers to
consider the merits of this philosophy in themselves
and in the leadership structure of their organiza-
tions. This deceptively simple but powerful approach
to leadership can lead both to excellent results for
our organizations and to profound meaning in the
lives of those it touches.
The statements and opinions contained in this editorial
are solely those of the coeditors in chief.
FINANCIAL DISCLOSURES
None reported.
eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Submit a response” in either the full-text or PDF
view of the article.
REFERENCES
1. Wilson RT. Servant leadership. Physician Exec. 1998;24
(5):6-12.
2. Schwartz RW, Tumblin TF. The power of servant leadership
to transform health care organizations for the 21st-century
economy. Arch Surg. 2002;137(12):1419-1427.
3. Anderson RJ. Building hospital-physician relationships
through servant leadership. Front Health Serv Manage.
2003;20(2):43-47.
4. Greenleaf RK. The Servant as Leader. Westfield, IN: The
Greenleaf Center for Servant Leadership; 1970.
5. Greenleaf RK. The Power of Servant Leadership. San Fran-
cisco, CA: Berrett-Koehler Publishers, Inc; 1998.
6. Autry JA. The Servant Leader: How to Build a Creative
Team, Develop Great Morale, and Improve Bottom-Line
Performance. New York, NY: Crown Business; 2004.
7. Howatson-Jones IL. The servant leader. Nurs Manag (Har-
row). 2004;11(3):20-24.
8. Hunter JC. The World's Most Powerful Leadership Princi-
ple: How to Become a Servant Leader. New York, NY:
Crown Publishing Group; 2004.
9. Sipe JW, Frick DM. Seven Pillars of Servant Leadership:
Practicing the Wisdom of Leading by Serving. Mahway, NJ:
Paulist Press; 2009.
10. Jenkins M, Stewart AC. The importance of a servant leader
orientation. Health Care Manage Rev. 2010;35(1):46-54.
11. Waterman H. Principles of “servant leadership” and how
they can enhance practice. Nurs Manag (Harrow). 2011;17
(9):24-26.
12. Boden TW. The first shall be last: the essence of servant-
leadership. J Med Pract Manage. 2014;29(6):378-379.
13. Trastek VF, Hamilton NW, Niles EE. Leadership models in
health care —a case for servant leadership. Mayo Clin
Proc. 2014;89(3):374-381.
To purchase electronic or print reprints, contact American
Association of Critical-Care Nurses, 101 Columbia, Aliso
Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
A true servant leader is determined to remain modest
calm, and focused on giving credit to others.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 99
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
ronment where the people in the organization want
to “give it their all,” and by extension the organiza-
tion does well.
Challenges to Implementation
We would be remiss if we did not mention
some of the challenges to implementation of a ser-
vant leadership culture in an organization. First of
all, most medical centers and medical schools are
still organized into department silos, each with its
own leaders. Leaders of those departments must
take the initiative to focus on servant leadership.
Second, some may be uncomfortable with the ser-
vant leadership model, preferring the more tradi-
tional autocratic style. Regardless, we feel that
servant leadership specifically and explicitly fits well
with the overall goals of critical care nursing and
medicine: never take your eye off the ball; that is,
the patient comes first. Many obstacles to servant
leadership must be overcome so our teams can be
the best they can be.
Conclusions
As we reflect more deeply about this approach
to leadership, perhaps we realize that it is more
than just a leadership style, but a philosophy of life.
Servant leadership permits us to demonstrate lead-
ership without requiring the spotlight. It is a leader-
ship style in which the emphasis is on leading while
being unassuming: an opportunity to lead and let
others take the credit. Servant leadership stresses the
importance of aspirations for the organization
rather than ambitions for a particular person:
humility, collaboration, and a meaningful work
experience lead to positive results. What is exciting
about servant leadership is that it allows people
who may not have a classic leadership personality
(eg, outgoing, take-charge, seeking the spotlight) to
step forward and say, “I would like to help here.” It
allows all of us to see that there is a style of leader-
ship whereby leaders are there to support the orga-
nization and support us.
There is much to read about servant leadership,
and so we have included additional references.6-13
With this editorial we hope to have stimulated some
thought and encouraged further dialogue on the
topic of servant leadership. We wish for readers to
consider the merits of this philosophy in themselves
and in the leadership structure of their organiza-
tions. This deceptively simple but powerful approach
to leadership can lead both to excellent results for
our organizations and to profound meaning in the
lives of those it touches.
The statements and opinions contained in this editorial
are solely those of the coeditors in chief.
FINANCIAL DISCLOSURES
None reported.
eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Submit a response” in either the full-text or PDF
view of the article.
REFERENCES
1. Wilson RT. Servant leadership. Physician Exec. 1998;24
(5):6-12.
2. Schwartz RW, Tumblin TF. The power of servant leadership
to transform health care organizations for the 21st-century
economy. Arch Surg. 2002;137(12):1419-1427.
3. Anderson RJ. Building hospital-physician relationships
through servant leadership. Front Health Serv Manage.
2003;20(2):43-47.
4. Greenleaf RK. The Servant as Leader. Westfield, IN: The
Greenleaf Center for Servant Leadership; 1970.
5. Greenleaf RK. The Power of Servant Leadership. San Fran-
cisco, CA: Berrett-Koehler Publishers, Inc; 1998.
6. Autry JA. The Servant Leader: How to Build a Creative
Team, Develop Great Morale, and Improve Bottom-Line
Performance. New York, NY: Crown Business; 2004.
7. Howatson-Jones IL. The servant leader. Nurs Manag (Har-
row). 2004;11(3):20-24.
8. Hunter JC. The World's Most Powerful Leadership Princi-
ple: How to Become a Servant Leader. New York, NY:
Crown Publishing Group; 2004.
9. Sipe JW, Frick DM. Seven Pillars of Servant Leadership:
Practicing the Wisdom of Leading by Serving. Mahway, NJ:
Paulist Press; 2009.
10. Jenkins M, Stewart AC. The importance of a servant leader
orientation. Health Care Manage Rev. 2010;35(1):46-54.
11. Waterman H. Principles of “servant leadership” and how
they can enhance practice. Nurs Manag (Harrow). 2011;17
(9):24-26.
12. Boden TW. The first shall be last: the essence of servant-
leadership. J Med Pract Manage. 2014;29(6):378-379.
13. Trastek VF, Hamilton NW, Niles EE. Leadership models in
health care —a case for servant leadership. Mayo Clin
Proc. 2014;89(3):374-381.
To purchase electronic or print reprints, contact American
Association of Critical-Care Nurses, 101 Columbia, Aliso
Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
A true servant leader is determined to remain modest
calm, and focused on giving credit to others.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 99
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
Richard H. Savel and Cindy L. Munro
Servant Leadership: The Primacy of Service
http://ajcc.aacnjournals.org/Published online
©2017 American Association of Critical-Care Nurses
10.4037/ajcc201735697-99262017;Am J Crit Care
http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Personal use only. For copyright permission information:
http://ajcc.aacnjournals.org/subscriptions/
Subscription Information
http://ajcc.aacnjournals.org/misc/ifora.xhtml
Information for authors
http://www.editorialmanager.com/ajcc
Submit a manuscript
http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
Email alerts
.532. Fax: (949) 362-2049. Copyright ©2016 by AACN. All rights reserved
(AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext.
The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
Servant Leadership: The Primacy of Service
http://ajcc.aacnjournals.org/Published online
©2017 American Association of Critical-Care Nurses
10.4037/ajcc201735697-99262017;Am J Crit Care
http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Personal use only. For copyright permission information:
http://ajcc.aacnjournals.org/subscriptions/
Subscription Information
http://ajcc.aacnjournals.org/misc/ifora.xhtml
Information for authors
http://www.editorialmanager.com/ajcc
Submit a manuscript
http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
Email alerts
.532. Fax: (949) 362-2049. Copyright ©2016 by AACN. All rights reserved
(AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext.
The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses
by AACN on March 4, 2017http://ajcc.aacnjournals.org/Downloaded from
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