[The nurse] could not, however, wear her mask in the hallways, or the cafeteria or any of the hospital’s common areas, because her supervisors told her it would scare patients. “I was told if I wanted to wear a mask, I would not be working there,” she said. “So I said I’m not willing to put my life at risk, and my contract was terminated.”
—Davenport etal. (Reference Davenport, Bhattarai and McGregor2020)
Nurses have risen to the occasion combating COVID-19 head on. Around the world, they have been recognized as heroes for their work on the front line (e.g., Natarajan etal., Reference Natarajan, Lowen and Parkinson2020). But with the relentless onslaught of COVID-19Footnote 1 and a widespread shortage of adequate personal protective equipment (PPE; e.g., National Nurses United, 2020), nurses find themselves in incredibly hazardous work environments. In their focal article on pandemics and industrial-organizational (I-O) psychology, Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) mention that during a disease outbreak, healthcare workers, especially nurses, are susceptible to experiencing increased strain that may result in risky behaviors (e.g., poor hand hygiene) and decreased well-being. Yet, nurses are expected to demonstrate resilience during crises—an expectation that some nursing scholars contend offloads occupational well-being responsibilities from the healthcare organization to the individual nurse (Maben & Bridges, Reference Maben and Bridges2020). Additionally, nurses working during the COVID-19 pandemic also face stressors in the form of questionable healthcare administration practices that imply a lack of supervisor support (e.g., Davenport etal., Reference Davenport, Bhattarai and McGregor2020).
It is evident that nurses require more support and that now, more than ever, good leadership is needed in nursing management. Indeed, in a recent nursing journal editorial on COVID-19, the editors emphasized the importance of leader-provided support for nurses amid the pandemic (Maben & Bridges, Reference Maben and Bridges2020). We agree with Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) that endeavoring to conceptualize “a novel ‘COVID-19 pandemic crisis leadership behavior’ construct” (p. 35) would be a waste of resources. Thus, from an I-O psychology perspective, we focus on applying servant leadership—which is naturally aligned with the values, roles, and responsibilities of healthcare professionals—to nursing management so that nurses can receive the support they need during the COVID-19 pandemic and future health crises.
Servant leadership and nursing management during the COVID-19 pandemic
Demonstrating concern, respect, and appreciation for followers and caring about followers’ welfare are leadership behaviors that are particularly important for leader effectiveness and followers’ job attitudes and motivation (Judge etal., Reference Judge, Piccolo and Ilies2004). Consideration and concern for followers underlie servant leadership, defined as “an (1) other-oriented approach to leadership (2) manifested through one-on-one prioritizing of follower individual needs and interests, (3) and outward reorienting of their concern for self towards concerns for others within the organization and the larger community” (Eva etal., Reference Eva, Robin, Sendjaya, van Dierendonck and Liden2019, p. 114, emphasis in original). Previous research suggests that servant leadership positively affects work engagement, organizational identification, and psychological empowerment during times of uncertainty across cultures and contexts (see de Sousa & van Dierendonck, Reference de Sousa and van Dierendonck2014). According to some scholars, focusing on individual servant leadership dimensions does not adequately capture the leadership construct’s complexity (e.g., Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Thus, we discuss the application of seven core servant leadership dimensions to improve nursing management effectiveness during the COVID-19 pandemic.
1. Servant leaders engage in emotional healing when they are sensitive to their followers’ personal concerns and well-being (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). Although this dimension of servant leadership aligns with nurses’ treatment of patients, whose health and emotional needs are paramount, nurses do not always receive the same treatment from their leaders. With the ongoing nursing shortage (Marć etal., Reference Marć, Bartosiewicz, Burzyńska, Chmiel and Januszewicz2019) amplified by healthcare organizations experiencing COVID-19-related staffing shortages (Centers for Disease Control, 2020c), a servant leader nurse manager should prevent and remedy staffing issues by coordinating schedules with staff nurses while actively considering these nurses’ individual needs and preferences.
2. The servant leader puts their followers first—even above themself or the organization (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). As with emotional healing, this servant leadership behavior clearly aligns with patient care. Nurses often skip mealtime breaks and even bathroom breaks during a shift because they are busy attending to patients, whose needs are top priority. In opposition to the hospitality approach to healthcare many health care systems have adopted (e.g., Rosenthal, Reference Rosenthal2013), the servant leader nurse manager would recognize, particularly during a pandemic, that although patient satisfaction is important, providing staff nurses with resources so that their needs are met will ultimately result in superior patient care. For example, staff nurses should be encouraged to take their breaks with managers stepping in to relieve these nurses and care for patients—despite COVID-19 pandemic requirements to doff and don PPE and wash hands more frequently before and after breaks taking up extra time.
3. Although to servant leaders meeting organizational objectives is actually secondary to meeting followers’ needs (Stone etal., Reference Stone, Russell and Patterson2004), servant leaders remain knowledgeable of their organizations’ goals as well as what is required to perform one’s job well (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). Having such conceptual skills enables leaders to solve problems and help their followers and organization succeed (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Nurse managers were staff nurses before they were managers; therefore, they are uniquely able to consider both the organization’s and their followers’ goals as they work to address pandemic-related issues. For example, a servant leader nurse manager understands that even amid widespread PPE shortages, their staff nurses require proper PPE to feel safe and provide proper care. In light of their healthcare facility’s inability to obtain adequate PPE, a servant leader nurse manager should make use of their conceptual skills to advocate to hospital leadership for the decontamination and reuse of PPE per the recommendations from the Centers for Disease Control (2020a).
4. Servant leaders help followers grow and succeed (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). To that end, a servant leader nurse should consider advocating for nurse educators and nurse preceptors to receive formal training on how to train their fellow nurses effectively or even take on an active role in such training. I-O psychologists have identified “training the trainer” as a best practice for improving on-the-job training (e.g., Derouin etal., Reference Derouin, Parrish and Salas2005), and some nursing programs have implemented such training for their clinical faculty (e.g., Bell-Scriber & Morton, Reference Bell-Scriber and Morton2009). Effective training is especially important for preparing nurses and other healthcare professionals to successfully navigate emergency scenarios (e.g., see Fung etal., Reference Fung, Boet, Bould, Qosa, Perrier, Tricco, Tavares and Reeves2015). Thus, servant leader nurse managers should ensure that trainers and trainees are receiving effective training to improve patient care during COVID-19 and to better prepare nurses for future health crises.
5.
Behaving ethically involves acting in a way that is honest and trustworthy and modeling this behavior for others (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Beyond considering the importance of ethical practices with respect to patient care, it is essential that the servant leader nurse manager demonstrates awareness and concern for ethical considerations regarding the nurses under their supervision. Despite various personal and family needs and vulnerabilities, and limited access to essential resources such as PPE, nurses have been called on to put themselves at increased risk during the COVID-19 pandemic. Thus, it is critical for nurse managers to clarify employer and employee expectations during the pandemic and effectively communicate with and support followers without threat of retaliation for raising concerns (American Nurses Association, n.d.).
6.
Empowering followers occurs when leaders delegate responsibility to followers, support followers’ autonomy in executing work tasks, and allow followers to influence decision-making (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Nurses’ job autonomy is positively related to employee outcomes such as job satisfaction and turnover intention (Nei etal., Reference Nei, Snyder and Litwiller2015; Zangaro & Soeken, Reference Zangaro and Soeken2007). Yet, healthcare employees, even under typical circumstances, face many work demands, and they often have little job control and strictly scheduled work hours as a result of regulated nurse–patient ratios (Odle-Dusseau etal., Reference Odle-Dusseau, Hammer, Crain and Bodner2016). Many nurses lack adequate support for meeting personal and family needs, are in a vulnerable population themselves, or have personal concerns regarding the provision of care during health crises (American Nurses Association, n.d.). Further, many hospitals are imposing visitor restrictions (e.g., requiring face coverings), and nurses are left to enforce these restrictions with little support from leaders. To empower followers, the servant leader nurse manager should provide a reasonable degree of flexibility and autonomy in solving scheduling or assignment issues through negotiation with other nurses and demonstrate support for nurses’ decisions regarding the enforcement of visitor restrictions. For example, nurses who do not have vulnerable household members may be willing to volunteer to work in place of those who have family members that are especially vulnerable during a pandemic, and nurse managers could get involved or encourage staff nurses to directly contact security when visitors refuse to comply with staff nurses’ face-covering requests.
7.
Creating value for the community encompasses leaders’ efforts to give back to the community surrounding the organization while encouraging followers to do so as well (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). By healing community members during the COVID-19 pandemic, nurses are directly creating value for their communities. As nurse managers are healthcare professionals themselves, this dimension of servant leadership is readily applicable to nursing management. For example, the servant leader nurse manager could demonstrate care for the community by encouraging other nurses, patients, families, and the broader community to do their part to prevent community spread by physically distancing, wearing face coverings, and engaging in general hygiene practices. Doing so also shows that the manager puts their staff nurses first by protecting followers as well as other frontline workers who will in turn safely continue to serve the community. The servant leader nurse manager could also create value for the community during the pandemic by volunteering their skills and knowledge to assist community members who are in need while encouraging their staff nurses to do the same (see American Nurses Association Enterprise, n.d.).
Although servant leadership has appeared in the nursing management literature (e.g., Neill & Saunders, Reference Neill and Saunders2008), this leadership style seems to be absent from actual nursing management practice during the COVID-19 pandemic. In fact, nursing does not seem to place an emphasis on nursing leadership in general (e.g., Leininger, Reference Leininger1974). Many nurse managers are staff nurses who outgrew floor nursing. They are often promoted to leadership positions as a result of accumulated experience in the field and/or organizational politics as opposed to their demonstration of actual leadership skills or potential. Their management training often exclusively comes in the form of annual corporate training classes offered to all leaders in the healthcare organization. Although there is a need for formal nurse leadership training and development programs (see Broom, Reference Broom2020), nurses’ professional values (e.g., human dignity, integrity, altruism, justice; Schmidt & McArthur, Reference Schmidt and McArthur2017) are clearly aligned with the principles of servant leadership (Fahlberg & Toomey, Reference Fahlberg and Toomey2016). Recent calls for nursing management to seriously consider adopting a servant leadership philosophy (e.g., Tropello & DeFazio, Reference Tropello and Defazio2014) and the increased recognition of nurses during health crises suggest that it is time for nurse managers and other healthcare leaders to consider shifting their focus from patient satisfaction to serving nurses. As hospitals are vital to community health and are in desperate need of skilled healthcare professionals to serve the public in a pandemic, serving nurses will enable hospitals to stay ahead of the increased demand for beds and ultimately better serve the community.
Concluding remarks
Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) conclude their focal article with a call to action for I-O psychologists to innovatively address work-related issues during COVID-19 and future health crises. We contend that during health crises, servant leadership is especially important for nurses, other healthcare professionals, and other frontline workers. We encourage I-O psychologists to bring best practices to nursing management and healthcare administration by actively partnering—for example, through collaborative research or consulting—with healthcare organizations. We believe that servant leadership can provide nurses—who, along with midwives, constitute approximately half of the global healthcare workforce (World Health Organization, 2016)—with much-needed support during the global COVID-19 pandemic and future health crises.
[The nurse] could not, however, wear her mask in the hallways, or the cafeteria or any of the hospital’s common areas, because her supervisors told her it would scare patients. “I was told if I wanted to wear a mask, I would not be working there,” she said. “So I said I’m not willing to put my life at risk, and my contract was terminated.”
—Davenport etal. (Reference Davenport, Bhattarai and McGregor2020)Nurses have risen to the occasion combating COVID-19 head on. Around the world, they have been recognized as heroes for their work on the front line (e.g., Natarajan etal., Reference Natarajan, Lowen and Parkinson2020). But with the relentless onslaught of COVID-19Footnote 1 and a widespread shortage of adequate personal protective equipment (PPE; e.g., National Nurses United, 2020), nurses find themselves in incredibly hazardous work environments. In their focal article on pandemics and industrial-organizational (I-O) psychology, Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) mention that during a disease outbreak, healthcare workers, especially nurses, are susceptible to experiencing increased strain that may result in risky behaviors (e.g., poor hand hygiene) and decreased well-being. Yet, nurses are expected to demonstrate resilience during crises—an expectation that some nursing scholars contend offloads occupational well-being responsibilities from the healthcare organization to the individual nurse (Maben & Bridges, Reference Maben and Bridges2020). Additionally, nurses working during the COVID-19 pandemic also face stressors in the form of questionable healthcare administration practices that imply a lack of supervisor support (e.g., Davenport etal., Reference Davenport, Bhattarai and McGregor2020).
It is evident that nurses require more support and that now, more than ever, good leadership is needed in nursing management. Indeed, in a recent nursing journal editorial on COVID-19, the editors emphasized the importance of leader-provided support for nurses amid the pandemic (Maben & Bridges, Reference Maben and Bridges2020). We agree with Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) that endeavoring to conceptualize “a novel ‘COVID-19 pandemic crisis leadership behavior’ construct” (p. 35) would be a waste of resources. Thus, from an I-O psychology perspective, we focus on applying servant leadership—which is naturally aligned with the values, roles, and responsibilities of healthcare professionals—to nursing management so that nurses can receive the support they need during the COVID-19 pandemic and future health crises.
Servant leadership and nursing management during the COVID-19 pandemic
Demonstrating concern, respect, and appreciation for followers and caring about followers’ welfare are leadership behaviors that are particularly important for leader effectiveness and followers’ job attitudes and motivation (Judge etal., Reference Judge, Piccolo and Ilies2004). Consideration and concern for followers underlie servant leadership, defined as “an (1) other-oriented approach to leadership (2) manifested through one-on-one prioritizing of follower individual needs and interests, (3) and outward reorienting of their concern for self towards concerns for others within the organization and the larger community” (Eva etal., Reference Eva, Robin, Sendjaya, van Dierendonck and Liden2019, p. 114, emphasis in original). Previous research suggests that servant leadership positively affects work engagement, organizational identification, and psychological empowerment during times of uncertainty across cultures and contexts (see de Sousa & van Dierendonck, Reference de Sousa and van Dierendonck2014). According to some scholars, focusing on individual servant leadership dimensions does not adequately capture the leadership construct’s complexity (e.g., Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Thus, we discuss the application of seven core servant leadership dimensions to improve nursing management effectiveness during the COVID-19 pandemic.
1. Servant leaders engage in emotional healing when they are sensitive to their followers’ personal concerns and well-being (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). Although this dimension of servant leadership aligns with nurses’ treatment of patients, whose health and emotional needs are paramount, nurses do not always receive the same treatment from their leaders. With the ongoing nursing shortage (Marć etal., Reference Marć, Bartosiewicz, Burzyńska, Chmiel and Januszewicz2019) amplified by healthcare organizations experiencing COVID-19-related staffing shortages (Centers for Disease Control, 2020c), a servant leader nurse manager should prevent and remedy staffing issues by coordinating schedules with staff nurses while actively considering these nurses’ individual needs and preferences.
2. The servant leader puts their followers first—even above themself or the organization (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). As with emotional healing, this servant leadership behavior clearly aligns with patient care. Nurses often skip mealtime breaks and even bathroom breaks during a shift because they are busy attending to patients, whose needs are top priority. In opposition to the hospitality approach to healthcare many health care systems have adopted (e.g., Rosenthal, Reference Rosenthal2013), the servant leader nurse manager would recognize, particularly during a pandemic, that although patient satisfaction is important, providing staff nurses with resources so that their needs are met will ultimately result in superior patient care. For example, staff nurses should be encouraged to take their breaks with managers stepping in to relieve these nurses and care for patients—despite COVID-19 pandemic requirements to doff and don PPE and wash hands more frequently before and after breaks taking up extra time.
3. Although to servant leaders meeting organizational objectives is actually secondary to meeting followers’ needs (Stone etal., Reference Stone, Russell and Patterson2004), servant leaders remain knowledgeable of their organizations’ goals as well as what is required to perform one’s job well (Liden etal., Reference Liden, Wayne, Zhao and Henderson2008). Having such conceptual skills enables leaders to solve problems and help their followers and organization succeed (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Nurse managers were staff nurses before they were managers; therefore, they are uniquely able to consider both the organization’s and their followers’ goals as they work to address pandemic-related issues. For example, a servant leader nurse manager understands that even amid widespread PPE shortages, their staff nurses require proper PPE to feel safe and provide proper care. In light of their healthcare facility’s inability to obtain adequate PPE, a servant leader nurse manager should make use of their conceptual skills to advocate to hospital leadership for the decontamination and reuse of PPE per the recommendations from the Centers for Disease Control (2020a).
4. Servant leaders help followers grow and succeed (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). To that end, a servant leader nurse should consider advocating for nurse educators and nurse preceptors to receive formal training on how to train their fellow nurses effectively or even take on an active role in such training. I-O psychologists have identified “training the trainer” as a best practice for improving on-the-job training (e.g., Derouin etal., Reference Derouin, Parrish and Salas2005), and some nursing programs have implemented such training for their clinical faculty (e.g., Bell-Scriber & Morton, Reference Bell-Scriber and Morton2009). Effective training is especially important for preparing nurses and other healthcare professionals to successfully navigate emergency scenarios (e.g., see Fung etal., Reference Fung, Boet, Bould, Qosa, Perrier, Tricco, Tavares and Reeves2015). Thus, servant leader nurse managers should ensure that trainers and trainees are receiving effective training to improve patient care during COVID-19 and to better prepare nurses for future health crises.
5. Behaving ethically involves acting in a way that is honest and trustworthy and modeling this behavior for others (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Beyond considering the importance of ethical practices with respect to patient care, it is essential that the servant leader nurse manager demonstrates awareness and concern for ethical considerations regarding the nurses under their supervision. Despite various personal and family needs and vulnerabilities, and limited access to essential resources such as PPE, nurses have been called on to put themselves at increased risk during the COVID-19 pandemic. Thus, it is critical for nurse managers to clarify employer and employee expectations during the pandemic and effectively communicate with and support followers without threat of retaliation for raising concerns (American Nurses Association, n.d.).
6. Empowering followers occurs when leaders delegate responsibility to followers, support followers’ autonomy in executing work tasks, and allow followers to influence decision-making (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). Nurses’ job autonomy is positively related to employee outcomes such as job satisfaction and turnover intention (Nei etal., Reference Nei, Snyder and Litwiller2015; Zangaro & Soeken, Reference Zangaro and Soeken2007). Yet, healthcare employees, even under typical circumstances, face many work demands, and they often have little job control and strictly scheduled work hours as a result of regulated nurse–patient ratios (Odle-Dusseau etal., Reference Odle-Dusseau, Hammer, Crain and Bodner2016). Many nurses lack adequate support for meeting personal and family needs, are in a vulnerable population themselves, or have personal concerns regarding the provision of care during health crises (American Nurses Association, n.d.). Further, many hospitals are imposing visitor restrictions (e.g., requiring face coverings), and nurses are left to enforce these restrictions with little support from leaders. To empower followers, the servant leader nurse manager should provide a reasonable degree of flexibility and autonomy in solving scheduling or assignment issues through negotiation with other nurses and demonstrate support for nurses’ decisions regarding the enforcement of visitor restrictions. For example, nurses who do not have vulnerable household members may be willing to volunteer to work in place of those who have family members that are especially vulnerable during a pandemic, and nurse managers could get involved or encourage staff nurses to directly contact security when visitors refuse to comply with staff nurses’ face-covering requests.
7. Creating value for the community encompasses leaders’ efforts to give back to the community surrounding the organization while encouraging followers to do so as well (Liden etal., Reference Liden, Wayne, Meuser, Hu, Wu and Liao2015). By healing community members during the COVID-19 pandemic, nurses are directly creating value for their communities. As nurse managers are healthcare professionals themselves, this dimension of servant leadership is readily applicable to nursing management. For example, the servant leader nurse manager could demonstrate care for the community by encouraging other nurses, patients, families, and the broader community to do their part to prevent community spread by physically distancing, wearing face coverings, and engaging in general hygiene practices. Doing so also shows that the manager puts their staff nurses first by protecting followers as well as other frontline workers who will in turn safely continue to serve the community. The servant leader nurse manager could also create value for the community during the pandemic by volunteering their skills and knowledge to assist community members who are in need while encouraging their staff nurses to do the same (see American Nurses Association Enterprise, n.d.).
Although servant leadership has appeared in the nursing management literature (e.g., Neill & Saunders, Reference Neill and Saunders2008), this leadership style seems to be absent from actual nursing management practice during the COVID-19 pandemic. In fact, nursing does not seem to place an emphasis on nursing leadership in general (e.g., Leininger, Reference Leininger1974). Many nurse managers are staff nurses who outgrew floor nursing. They are often promoted to leadership positions as a result of accumulated experience in the field and/or organizational politics as opposed to their demonstration of actual leadership skills or potential. Their management training often exclusively comes in the form of annual corporate training classes offered to all leaders in the healthcare organization. Although there is a need for formal nurse leadership training and development programs (see Broom, Reference Broom2020), nurses’ professional values (e.g., human dignity, integrity, altruism, justice; Schmidt & McArthur, Reference Schmidt and McArthur2017) are clearly aligned with the principles of servant leadership (Fahlberg & Toomey, Reference Fahlberg and Toomey2016). Recent calls for nursing management to seriously consider adopting a servant leadership philosophy (e.g., Tropello & DeFazio, Reference Tropello and Defazio2014) and the increased recognition of nurses during health crises suggest that it is time for nurse managers and other healthcare leaders to consider shifting their focus from patient satisfaction to serving nurses. As hospitals are vital to community health and are in desperate need of skilled healthcare professionals to serve the public in a pandemic, serving nurses will enable hospitals to stay ahead of the increased demand for beds and ultimately better serve the community.
Concluding remarks
Rudolph etal. (Reference Rudolph, Allan, Clark, Hertel, Hirschi, Kunze, Shockley, Shoss, Sonnentag and Zacher2021) conclude their focal article with a call to action for I-O psychologists to innovatively address work-related issues during COVID-19 and future health crises. We contend that during health crises, servant leadership is especially important for nurses, other healthcare professionals, and other frontline workers. We encourage I-O psychologists to bring best practices to nursing management and healthcare administration by actively partnering—for example, through collaborative research or consulting—with healthcare organizations. We believe that servant leadership can provide nurses—who, along with midwives, constitute approximately half of the global healthcare workforce (World Health Organization, 2016)—with much-needed support during the global COVID-19 pandemic and future health crises.