Examining the role of a servant-leadership paradigm
in a neonatal intensive care unit
Over 15-million babies are born premature each year worldwide. Prematurity is defined as a birth that occurs before 37-weeks gestation. ("Preterm Birth," 2014). In the United States, 11.4% (1 in 9 babies) or a total of 450,000 births occur each year ("Home | March of Dimes," n.d.). Premature birth can lead to lifelong developmental challenges including difficulty in school or work, long-term medical issues and socio-psychological issues. In fiscal terms, it costs society $26 billion dollars per year. ("Home | March of Dimes," n.d.).
Families who have had a child in a Neonatal Intensive Care Unit (NICU) are at higher risk for anxiety, post-traumatic stress disorder and depression (Cleveland, 2008). Studies show families who receive emotional support, parent empowerment, a welcoming neonatal environment, and parent education with an opportunity to practice through guided participation are better equipped to care for a medically fragile infant following NICU hospitalization (Cleaveland, 2008). All of the previously listed tenets reflect the various tenets of servant-leadership.
Servant-leadership is an organizational philosophy in which, “a servant-leader may be defined as a leader whose primary purpose for leading is to serve others by investing in their development and well being for the benefit of accomplishing tasks and goals for the common good” (Page & Wong, n.a.). By incorporating servant-leadership characteristics in a NICU setting and modeling behaviors familiar to the servant-leadership paradigm, families and caregivers will not only have task-oriented tools in caring for a medically fragile infant but also transformational and interpersonal skills of individual and familial development.
The focus of my research is to conduct a qualitative phenomenological study examining care delivery in a NICU through a lens of servant-leadership. This qualitative research will provide a baseline for future exploration of the impact that the various tenets of servant-leadership play in the experience of families whose child is served in critical care environments such as a neonatal intensive care unit.
A review of the literature has revealed that a research study on the impacts of servant-leadership tenets in a neonatal intensive care unit has not been conducted to date. I collected seventeen articles, each specifically addressing servant-leadership tenets and their impact on medical care delivery. (Anderson, n.d.; Brewster, 2001; Dolan, 2013; Garber, Madigan, Click, & Fitzpatrick, 2009; Huckabee & Wheeler, 2011; Mahon, 2011; Mueller, 2011; Neill, Hayward, & Peterson, 2007; Neill & Saunders, 2008; Robinson, 2009; Rodriguez, 2010; Schwartz & Tumblin, 2002; Trastek, Hamilton, & Niles, 2014; Waterman, 2011; Yanofchick, 2007). Since none of these articles specify care provided in a NICU, nor the impact these tenets might have on families with a child in the NICU, this research offers the potential to fill a literature gap. By identifying tenets of servant-leadership with regard to care delivery in the NICU, I will offer a framework from which further research can be conducted.
Servant-leadership emphasizes, “increased service to others; a holistic approach to work; promoting a sense of community; and the sharing of power in decision making” (Page & Wong, n.a). In order to begin the lifelong journey of servant-leadership, individuals must, “undergo a journey of self-discovery and personal transformation” (Page &Wong, n.a.). A servant-leader in training must begin developing skills including: 1) listening 2) empathy 3) healing 4) awareness 5) persuasion 6) conceptualization, 7) foresight 8) stewardship 9) commitment to the growth of people and 10) building community (Spears, 2010).
There are advantages and disadvantages to servant-leadership in medicine. Advantages include: values people and treats them as an ends, not a means; enables others to develop and flourish; shows commitment to the community; expresses a human face in an often impersonal environment; puts back the concept of caring into care; seeks to improve care through encouragement and facilitation, rather than through power and authority; improves performance by developing and nurturing followers. It is the disadvantages that highlight ethical considerations of servant-leadership in a NICU environment: similar to transformational leadership approaches; falls into a target-fixated system; disturbs the concept of hierarchy; can be perceived as religious and therefore alien to modern sensitivities; the title of servant can be seen as detrimental to nurses; humility can be perceived as weakness; some workers may not respond to this approach (Waterman, 2011).
The servant-leadership paradigm, while it has no specific definition, is best seen through the lens of outcomes on the effects of society. “The best test, and difficult to administer, is this: 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 privileged in society? Will they benefit or at least not be further deprived?” (Greenleaf, 1977). One does not need to subscribe specifically to the tenets of the philosophy of servant-leadership. If the outcomes on those being served result in people who are, “healthier, wiser, freer, more autonomous” (Greenleaf, 1977) and develop a worldview committed to serving others, they are servant-leaders (Spears, 2014).
Medical care as a whole in the United States is in a state of major change. Medical staff is burdened by overwork and stress leading to a shortage of nurses (Shirey, 2006). Rebuilding trust and empowering medical staff to pursue leadership education and development to fully undertake leadership responsibilities is essential (Trastek, Hamilton & Niles, 2014). Managers agree that medical staff needs to be introduced to leadership models with an opportunity to develop their own theories which at times may be a blend of transformational and servant-leadership (Trastek, Hamilton & Niles, 2014). The theoretical basis is to explore existing research on the phenomenological influences of servant-leadership in a neonatal intensive care unit. In the absence of a specific research report within the neonatal intensive care unit, it is interpretive social science (ISS) that will be used to uncover the existing philosophy and research to support servant-leadership’s inclusion within the healthcare industry (Neuman, 2011). I will take a phenomenological approach towards exploring the developing awareness of medical staff when presented with characteristics common in the servant-leadership paradigm.
This research rationale seeks to examine existing care delivery in a Neonatal Intensive Care Unit through the lens of Servant-Leadership as outlined by Greenleaf (Greenleaf, 1977). Research on the tenets of servant-leadership has been studied from various perspectives in medicine and care (Anderson, n.d.; Brewster, 2001; Dolan, 2013; Garber, Madigan, Click, & Fitzpatrick, 2009; Huckabee & Wheeler, 2011; Mahon, 2011; Mueller, 2011; Neill, Hayward, & Peterson, 2007; Neill & Saunders, 2008; Robinson, 2009; Rodriguez, 2010; Schwartz & Tumblin, 2002; Trastek, Hamilton, & Niles, 2014; Waterman, 2011; Yanofchick, 2007). However, there is a gap in the literature with regard to the impact on the patient when the tenets of servant-leadership are examined in a neonatal intensive care unit. Since this is novel research, a qualitative phenomenological case study approach will be utilized to develop a framework for later quantitative research.
According to Alan Spitzer, M.D., prominent neonatologist, neonatal researcher and academician, neonatal medicine is in a state of organizational dysfunction (Spitzer, Alan. Personal interview. 13 September 2014). According to Spitzer, dysfunction in neonatal medicine is represented by 1) over-regulation 2) organizational initiatives accepted at regime-like fervor 3) the organizational grind of nursing as a career. Over-regulation includes federal fines for accidental information sharing; medical personnel spending an imbalance of time on paperwork and billing issues; federal oversight on donations to medical professionals limiting activities to $10 or less ("Physician Financial Transparency Reports (Sunshine Act)"). Organizational initiatives accepted at regime-like fervor include the adoption of “Baby-Friendly Hospital” ("Baby-Friendly Hospital Initiative," 2012) and “Family-Centered Care” (“Patient and Family-Centered Care”, 2015). Both initiatives emphasize the importance and engagement of a neonate’s family on the health and well being of the infant. The adoption of evidence based practices leads to strict rules requiring absolute adherence to the philosophies. The organizational grind of the nursing field has led to overworked, overtired and burnt-out nursing staff. If medicine would offer a better working environment with support to over-worked nurses, one would hope the burnt-out exhaustion would be replaced by self-initiative to improve on the job, grow and holistically develop (Spitzer, Alan. Personal interview. 13 September 2014; Brewster, 2001; Anderson, n.d.). My research is unique and challenging. While the impact on the employee and organization has been well documented, my research seeks to identify if healthy organizational practices lead to better health outcomes for the neonate.
RQ1: Do NICUs that ascribe to the tenets of servant-leadership achieve better outcomes?
RQ2: How can tenets of servant-leadership improve NICU working environments to therefore affect outcomes for a NICU family?
This study will use an exploratory phenomenological case study to develop its findings. According to Houghton, Casey, Shaw and Murphy, “There is an increasing recognition of the valuable contribution qualitative research can make to nursing
knowledge…qualitative research is being valued for its differences to quantitative research rather than being perceived as having methodological shortcomings in comparison” (pg. 2).
Additionally, “There are different criteria used to assess the rigor of qualitative research but the most commonly used are those proposed by Lincoln and Guba (1985): credibility, dependability, conformability and transferability” (Houghton, Casey, Shaw & Murphy, 2012; Lincoln & Guba 1985). According to Stake (2003) and Yin (2003), “case study research is useful for the in-depth study of a phenomenon in its natural context (Houghton, Casey, Shaw and Murphy, 2012; Stake, 1995; Yin, 2003). Some researchers question the credibility of qualitative research as sub-standard to quantitative research, however, Lincoln and Guba (1985) outline four criteria that establish the framework for rigorous qualitative research: credibility, dependability, conformability, and transferability (Houghton, Casey, Shaw & Murphy, 2012, Lincoln & Guba, 1985;). Credibility indicates the research has value and believability. Dependability refers to how reliable the data collected is to the research. Conformability refers to how accurate and reliable the data collected is of the research. And transferability requires that the research conducted can be transferred to a similar institution (Graneheim and Lundman, 2004; Houghton, Casey, Shaw & Murphy, 2012; Lincoln & Guba, 1985; Leininger, 1994; Polit and Tatano Beck, 2006; Shah & Corley, 2006; Tobin & Begley, 2004; Rolfe, 2006). Credibility of data collection will be further augmented through triangulation, with “the two main purposes of triangulation being confirmation of the data and for completeness of the data” (Houghton, Casey, Shaw & Murphy, 2012).
This study will focus on two similar Level 3 NICU’s spaced 600-miles apart, one in Oregon, one in California. Both NICU’s have approximately 30 staff each and are accessible by this researcher due to existing relationships established through a combination of personal and professional experience. The scope of this research should include a minimum of twenty surveys and ten interviews.
This study was approved by the Gonzaga Institutional Review Board (IRB), IRB # XXXXXXXX. In accordance with IRB approval, this study will use SurveyGizmo to confidentially collect survey responses. Open-ended survey questions will be used to ascertain perceptions of servant-leadership and how these tenets play a role within a neonatal intensive care unit. The survey will use a branch A/B/C system of inquiry. The initial question will identify the professional’s role within a neonatal intensive care unit: neonatologist, nurse or therapist. Subsequent questions will appear individually, recognizing that multiple questions can be perceived as overwhelming. There will be ten open-ended questions correlating to the ten common tenets of servant-leadership (Spears, 1995).
This study will also use case study telephone interviews with neonatal professionals to develop findings. Given that tenets of servant-leadership have not be specifically discussed within a neonatal intensive care unit, interview questions will lay an operational definition of servant-leadership and seek to collaborate and identify whether similarly defined characteristics are at work. Questions related to positive patient outcomes will be developed and later analyzed by the researcher to define what tenets of servant leadership exist within a NICU setting.
The use of two research modalities will seek to identify correlations between the open-ended results and the operational definition of servant-leadership. The feedback provided through survey and interview will be triangulated by academic research exploring servant-leadership in medicine. (Anderson, n.d.; Brewster, 2001; Dolan, 2013; Garber, Madigan, Click, & Fitzpatrick, 2009; Huckabee & Wheeler, 2011; Mahon, 2011; Mueller, 2011; Neill, Hayward, & Peterson, 2007; Neill & Saunders, 2008; Robinson, 2009; Rodriguez, 2010; Schwartz & Tumblin, 2002; Trastek, Hamilton, & Niles, 2014; Waterman, 2011; Yanofchick, 2007).
This study has a few ethical considerations. Research will be conducted on NICU staff working with a highly vulnerable and sensitive population. This researcher must remain cognizant of the complex work environment and present organizational issues when introducing a philosophically unique organizational approach. Servant-leadership is often referred to as a refreshing philosophy though, without proper training and support, this new philosophy might psychologically affect how nurses perceive their current work environment. Additionally, the title of servant-leadership may be construed as detrimental to nurses (Waterman, 2011). The nursing industry has worked hard in, “shedding it’s old image of vocation and dedication” (Waterman, 2011). The nursing career, “evolved out of religious institutions and vestiges” of being a religious sister (nun) (Waterman, 2011)
According to Ziegler (2011), elements of informed consent must incorporate: 1) a statement that includes that this study is research, the purposes of the research and the expected duration of research 2) a description of any foreseeable risks 3) a description of any benefits to the subject or others benefiting from research 4) a statement describing the extent, if any, to which confidentiality of records identifying the subject will be used 5) an explanation of who to contact regarding questions about this research and subjects’ rights and 6) a statement that participation is voluntary, a refusal to participate will involve no penalty or loss of benefits to which the subject is entitled and subject may discontinue participation at any time (Ziegler, 2011).
Every individual surveyed or interviewed must abide by the principle of informed consent. Information provided to participants will outline what Informed Consent is, as well as outlining the purpose and scope of the study and the fundamental ethical principles relating to participant rights as voluntary contributors. Research will go a step further and invite them to discontinue the survey or interview if the questions become incongruent or uncomfortable at any time. An example of informed consent is: “The information gathered in this study will be completely confidential. Your participation in this survey is voluntary. You may refuse to participate in this study or any part of this study with no harm to you. You may withdraw at any time. Your participation in this survey recognizes the above. This survey is only being sent to neonatal professionals (neonatologists, nurses and staff) working in the Neonatal Intensive Care Unit” (James, Slater, & Bucknam, 2012).
This researcher, citing concern relating to competency, will not interview families cared for in a NICU setting. Families in a critical care environment are overly occupied by the care and physical well-being of their neonate and said research could lead families on a psychological path that leads them to reflect on their existing care and direct their emotional trauma towards the inefficiencies of care in their NICU. This researcher will collect research from NICU staff only as competent participants able to consciously give true informed consent. Additionally, research will not be conducted in a NICU environment primarily due to laws of confidentiality protecting families from unnecessary additional stress.
If possible, research may be conducted on families who have graduated from a NICU environment 2+ years following care. It is a commonly accepted timeline for neonates and their families to recover from the critical elements of a NICU environment.
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