Strategic Visioning With Stakeholders

The impact of servant leadership dimensions on leader–member exchange among health care professionals

JAN JOHANSSON HANSE P hD 1,2, ULRIKA HARLIN MS c

3, CAROLINE JAREBRANT MS c 3,4,

KERSTIN ULIN P hD , RN 5,6 and J €ORGEN WINKEL P hD

7,8

1Professor, Department of Psychology, University of Gothenburg, Gothenburg, 2Professor, Nordic School of Public Health NHV, Gothenburg, 3Industrial Researcher, Swerea IVF, M€olndal, 4PhD Student, 5Senior Lecturer, Institute of Health and Care Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 6Senior Lecturer, Sahlgrenska University Hospital, Gothenburg, Sweden and 7Senior Professor, Department of Management Engineering, Technical University of Denmark, Kgs. Lyngby, Denmark, 8Senior Professor, Department of Sociology and Work Science, University of Gothenburg, Gothenburg, Sweden

Correspondence

Jan Johansson Hanse

Department of Psychology

University of Gothenburg

Box 100

SE-40530 Gothenburg

Sweden

E-mail: jan.johansson.hanse@psy.

gu.se

HANSE J.J., HARLIN U., JAREBRANT C., ULIN K. & WINKEL J. (2016) Journal of Nursing Management 24, 228–234. The impact of servant leadership dimensions on leader–member exchange

among health care professionals

Aim The aim of the current study was to investigate the impact of servant

leadership dimensions on leader–member exchange (LMX) among health-care

professionals. Background Leadership support and the quality of the dyadic relationship

between the leader and the employee are essential regarding the work

environment and turnover intentions in health care. Method A questionnaire-based cross-sectional study was undertaken at four

hospital units in Sweden. The study sample included 240 employees.

Results Significant bivariate correlations were found between all servant leadership dimensions and LMX. The strongest correlations were found between

‘humility’ and LMX (r = 0.69, P < 0.001), and ‘empowerment’ and LMX (r = 0.67, P < 0.001). The hierarchical regression analyses indicated that

‘empowerment’, ‘humility’ and ‘stewardship’ explained about 55% of the

variance in LMX. Conclusion In our study servant leadership dimensions were strongly related to

LMX.

Implications for nursing management The results identify specific servant leadership dimensions that are likely to be useful for developing a stronger

exchange relationship between the leader (e.g. nursing manager) and individual

subordinates in health care.

Keywords: health care, leader–member exchange, leadership, servant leadership,

social exchange

Accepted for publication: 8 March 2015

Introduction

One of the leadership concepts that have been in focus

in the past decade(s) is servant leadership. Greenleaf

(1977) proposed the concept of servant leadership and

the term ‘servant’ indicates an idea based on the

motivation to serve. Servant leaders want to develop a

sustainable organisation, bring out the best among

228 DOI: 10.1111/jonm.12304

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Journal of Nursing Management, 2016, 24, 228–234

employees and to serve the community (including to

serve patients) and to act as a steward of the environ-

ment (Liden et al. 2008, van Dierendonck & Nuijten

2011, Trastek et al. 2014). Servant leaders prioritise

the well-being and growth of followers, but also focus

on enabling employees to work more effectively, be

successful and to feel responsible for their work

(Greenleaf 1977, van Dierendonck 2011, van Diere-

ndonck & Nuijten 2011). Additionally, servant leader-

ship seems well suited to providing employees with

the empowerment related to both employee and

patient satisfaction, and has the potential to transform

culture within long-term care. Brownell (2010) points

out that servant leadership is directly aligned with the

mission of health-care organisations. Trastek et al.

(2014) lists three reasons why servant leadership is

especially applicable for health-care organisations:

focus on the strength of the team, developing trust,

and serving the needs of patients.

The servant leadership literature offers a varying set

of characteristics or dimensions. We are inspired by

van Dierendonck (2011) discussion and suggestion of

key characteristics of servant leadership that includes

accountability, empowerment, humility, stewardship

and standing back (Konczak et al. 2000, Morris et al.

2005, Hernandez 2008, van Dierendonck 2011, van

Dierendonck & Nuijten 2011). See Liden et al. (2008)

and van Dierendonck (2011) for a review of dimen-

sions and leadership models.

A leadership concept strongly coupled to social

exchange theory is leader–member exchange (LMX)

(Wayne et al. 1997, Cropanzano & Mitchell 2005).

LMX focuses on the relationship between the leader

and individual subordinates. LMX is about the quality

of the dyadic relationship between a worker and his/

her leader (supervisor). Empirical support can be

found for a four-dimensional LMX-model that

includes ‘loyalty’, ‘affect’, ‘contribution’ and ‘profes-

sional respect’ (Liden & Maslyn 1998). High-quality

LMX can be exemplified by high levels of mutual

trust, good communication, respect and reciprocal

influence (Liden & Graen 1980, Graen & Uhl-Bien

1995). High-quality LMX has been found to be posi-

tively linked to several employee-related outcomes,

including high performance, increased organisational

commitment, role clarity, recognition, satisfaction

with supervision, job satisfaction, low turnover inten-

tion and organisational citizenship behaviours (Gerst-

ner & Day 1997, Wayne et al. 1997, Schriesheim

et al. 1999, Ilies et al. 2007). In recent years, there

has been an increasing amount of literature focusing

on LMX for the health professions. For example,

Laschinger et al. (2007) investigated the quality rela-

tionships with nurse managers’ immediate supervisor

and found that high-quality LMX was related to more

empowerment and job satisfaction. In a study at medi-

cal centres and regional hospitals it was found that

high-quality LMX between the nurse and nurse super-

visor could increase nurses’ commitment, lessen turn-

over, and promote their organisational citizenship

behaviour (Chen et al. 2008). In a US hospital study,

Han and Jekel (2011) showed that job satisfaction

mediates the association between LMX and turnover

intentions. Also, in a study among nurses and nursing

assistants in Belgium the results showed that LMX

explained significant variance in retention-related out-

comes such as turnover intentions (Trybou et al.

2014). Thus, previous research emphasises the impor-

tance of the interaction between the supervisor and

employee.

Since servant leaders focus on building the leader-

ship potential in followers (employees) and growing

their followers into more capable members of the

organisation, it is plausible to develop high quality

LMX relationships in work groups (Greenleaf 1977,

Liden et al. 2008, 2014). Previous studies support the

conclusion that servant leadership is associated with,

but separate from, LMX (Anand et al. 2011, Wu

et al. 2013). Additionally, in a model of servant lead-

ership Liden et al. (2014) identified several intermedi-

ate processes such as mutual trust between leader and

follower, and commitment to supervisor. Therefore, it

may be argued that servant leadership facilitates the

development of high-quality LMX (Bauer & Green

1996, Liden et al. 2008, Anand et al. 2011, van Dier-

endonck 2011, Wu et al. 2013).

The aim of the current study was to investigate the

impact of servant leadership dimensions on leader–

member exchange (LMX) among health-care profes-

sionals. The study reports findings from the Swedish

part of a Nordic Multicenter Study regarding perfor-

mance and well-being in lean rationalisation processes

at hospitals (Winkel et al. 2012).

Methods

Procedure, ethical considerations and participants

A questionnaire-based cross-sectional study was under-

taken at four units in two not-for-profit hospitals in

southwestern Sweden. The selection of hospital units

was based on a two-step sample strategy: (1) the units

should represent typical hospital care and (2) the units

were easily accessible and willing to participate in the

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study. Oral and written information was given regard-

ing the main aims of the study along with assurances

that the study would follow research guidelines of confi-

dentiality. Following the organisational codes, the

department manager at the hospital gave permission to

conduct the study. The study was based on question-

naires carried out at the hospital units during working

time. The participation was voluntary and subjects

answered the questionnaire anonymously. The study

sample included 240 employees and the response rate

was approximately 80%. The data were collected

between 2011 and 2013.

Measures

Demographic and employee-related variables

This part included items concerning sex, age (6-point

response scale; younger than 20 years, 20–29 years,

30–39 years, 40–49 years, 50–59 years, 60 years or

older), years of employment at the hospital unit

(4-point response scale; less than 3 months,

3–12 months, 1–3 years, more than 3 years) and job

title/profession (5-point response scale; registered nurse,

enrolled nurse, secretary, physician, another position).

Servant leadership

Leadership was measured by the Servant Leadership

Survey (van Dierendonck & Nuijten 2011). A previ-

ous validation study suggests that there are five pri-

mary dimensions of servant leader behaviour (van

Dierendonck & Nuijten 2011). In the present study,

these five primary dimensions were used (with Cron-

bach’s alpha coefficients in brackets): ‘Empowerment’

(seven items, alpha = 0.88), ‘Accountability’ (three

items, alpha = 0.74), ‘Standing back’ (or Servitude)

(three items, alpha = 0.64), ‘Humility’ (five items,

alpha = 0.92), ‘Stewardship’ (three items, alpha = 0.71). Each item was rated using a six-point Likert-

type scale where high scores represent employees who

perceived high servant leadership behaviour in their

leaders (1 = strongly disagree to 6 = strongly agree).

Leader–member exchange

The quality of the supervisor–employee (‘follower’)

relationship was measured according to the Leader–

member exchange (LMX) concept (Graen & Scandura

1987). In the present study, employee-rated LMX was

measured with four items from Liden and Maslyn

(1998) LMX-scale: ‘affect’, ‘loyalty’, ‘contribution’

and ‘professional respect’. These four items represent

four sub-dimensions to measure the employees’ per-

ception of the quality of relationship with their

superiors. In the present study we used a short version

of the employee-rated LMX (Liden & Maslyn 1998)

with one item for each dimension. Each item was

rated using a seven-point Likert-type scale where

higher scores represent higher quality exchanges, i.e.

high-quality LMX (1 = strongly disagree to 7 = strongly agree). In the present study, Cronbach’s alpha

reliability for the LMX global scale was 0.87.

Data analyses

Descriptive data were analysed and reliabilities (Cron-

bach’s alpha coefficients) were computed for all servant

leadership dimensions and the LMX global scale. The

data were scrutinised using Pearson correlation (Pear-

son’s r) and hierarchical linear regression analysis to

assess the association between servant leadership

dimensions and LMX. In the hierarchical linear regres-

sion analysis the variables were entered in two (or

more) steps in the model in a preconceived order of

entry: demographic variables (method enter), servant

leadership dimensions (method stepwise). Multicollin-

earity among the variables in the regression models was

assessed by examining the variance inflation factor

(VIF). Values of VIF that exceed 10 are often regarded

as indicating high degree of multicollinearity, but even

VIF values of 3–5 may signify collinearity problems

(Hair et al. 2010). The significance level was set at 5%.

Effect-sizes were based on Cohen’s conventions (1988).

Cohen defined effect sizes for bivariate (zero-order) cor-

relations of around 0.10 as ‘small’, around 0.30 as

‘medium’ and around 0.50 as ‘large’. In multiple regres-

sion analysis (R2) the effect sizes are around 0.02 for

‘small’, around 0.13 for ‘medium’ and around 0.26 for

‘large’. Data management and analysis was performed

using SPSS version 21.0 for Windows (IBM Svenska AB,

Stockholm, Sweden).

Results

Demographic and employee-related variables among health-care professionals

The sample (n = 240, 82% females and 18% males)

consisted of 59% registered nurses, 24% enrolled

nurses, 10% secretaries and 6% physicians. Twenty-

three per cent were younger than 30 years, 62% were

between 30 and 49 years, and 15% were 50 years or

older. Twenty-three per cent had less than 1 year of

employment at the hospital, 17% between 1 and

3 years, and 60% had more than 3 years of employ-

ment.

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Bivariate correlations between servant leadership dimensions and LMX

Results of the Pearson’s r analysis yielded that there

were significant, positive correlations between all five

primary dimensions of servant leadership and LMX.

The correlations in descending order of strength were

with humility and LMX (r = 0.69, P < 0.001),

empowerment and LMX (r = 0.67, P < 0.001), stew-

ardship and LMX (r = 0.63, P < 0.001), standing

back and LMX (r = 0.54, P < 0.001), and account-

ability and LMX (r = 0.35, P < 0.001). The effect

sizes are large as regards four out of five correlations

between servant leadership dimensions and LMX, and

medium for the accountability dimension.

Regression analysis between servant leadership dimensions and LMX

Next, we examined the relationship between five ser-

vant leadership dimensions and LMX, after adjusting

for demographic variables in step 1 (see Table 1).

Multicollinearity was not a concern (VIF was between

1.01 and 2.81 in the regression models). The results of

hierarchical regression analyses indicated that, after

adjusting for demographic items, the servant leader-

ship dimension ‘empowerment’ had the strongest

impact on the employees’ ratings of LMX (see model

2 in Table 1). Three out of five servant leadership

dimensions had a significant positive relation with

LMX (see model 4 in Table 1). The final model in the

hierarchical regression analyses showed that ‘empow-

erment’, ‘humility’ and ‘stewardship’ explained about

55% of the variance in LMX. The effect sizes are

large in model 2–4 in the regression analysis (see

adjusted R2). Moreover, the servant leadership dimen-

sions ‘accountability’ and ‘standing back’ were not

significantly associated with LMX, when entered with

other variables (demographics and servant leadership

dimensions).

Discussion

The present study shows that a servant leadership

style positively influences high-quality LMX among

health-care professionals. It is interesting to note that

all five primary dimensions of servant leadership had

statistical significant bivariate (zero-order) correlations

to LMX. In the regression analysis, the strongest inde-

pendent variable on the dependent variable LMX was

the ‘empowerment’ dimension of servant leadership

(after controlling for age, sex and years of employ-

ment). The results suggest that servant leadership pro-

motes high-quality LMX.

A strong positive association between servant leader-

ship dimensions and LMX has been reported in the lit-

erature. In a cross-sectional US study among elected

public officials, Barbuto and Hayden (2011) found sig-

nificant, positive correlations between all servant lead-

ership dimensions and LMX (r 0.55–0.73). In a study

among hotel employees in China the correlation

between the servant leadership global scale and LMX

global scale was 0.41 (Wu et al. 2013). Thus, the results

in the current study are similar to those of Barbuto and

Hayden (2011) and Wu et al. (2013). The results of the

current study demonstrate that the bivariate correla-

tions were between 0.63 and 0.69 with regard to four

out of five servant leadership dimensions.

The present findings in the hierarchical regression

analysis seem to be consistent with research which

found that four of five dimensions of servant leader-

ship, entered into a stepwise hierarchical regression

model, explained approximately 63% of the variance

in LMX (Barbuto & Hayden 2011). By comparison,

in the present study, the hierarchical regression model

explained about 55% of the variance in LMX. These

Table 1

Hierarchical multiple regression analysis for servant leadership

dimensions on LMX (dependent variable). Demographic variables

were entered in step 1 (model 1) (n = 240)

B

SE

(B) b Adjusted

R2 F for change

in R2

Model 1

Age �0.05 0.09 �0.04 0.01 1.36

Sex 0.12 0.22 0.04

Years of

employment

�0.12 0.09 �0.10

Model 2

Age �0.03 0.06 �0.03 0.47*** 189.66*** Sex 0.05 0.16 0.02

Years of

employment

�0.07 0.07 �0.06

Empowerment 1.05 0.08 0.68*** Model 3

Age �0.02 0.06 �0.02 0.53*** 28.73*** Sex 0.15 0.15 0.05

Years of

employment

�0.04 0.06 �0.03

Empowerment 0.62 0.11 0.40*** Humility 0.52 0.10 0.38***

Model 4

Age �0.02 0.06 �0.02 0.55*** 11.74** Sex 0.14 0.15 0.04

Years of

employment

�0.04 0.06 �0.04

Empowerment 0.51 0.11 0.33*** Humility 0.37 0.11 0.27** Stewardship 0.33 0.09 0.23**

*P < 0.05, **P < 0.01, ***P < 0.001.

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two studies demonstrate large effect sizes when using

multiple regression analysis (Cohen 1988).

A servant leader culture involves interpersonal inter-

action and promotes strong relationships and trust

between leaders and employees, rather than relying

only on the economic incentives in the employment

contract. Servant-leadership moves the concept of lead-

ership to one that incorporates behaviours that are

effective, but also contribute to strong trust and

empowerment in both the health-care provider team

relationships and the patient relationship (Trastek et al.

2014). Brownell (2010) suggests that servant leadership

may be the new path forward for health-care leader-

ship. Previous studies suggest that servant leadership is

related to improved employee outcomes in health-care

organisations, for example job satisfaction, empower-

ing nurses to play a leadership role, professional

growth and ethical behaviour (Neill & Saunders 2008,

Sturm 2009). Trastek et al. (2014) suggest a number of

reasons why servant leadership is especially applicable

for health-care organisations, including development of

trust. As noted above, high-quality LMX includes a

high degree of mutual trust. This study provides empiri-

cal support for the argument that servant leadership

fosters high-quality LMX. Servant leadership is linked

to LMX in that servant leadership behaviours have an

impact on the development of good interpersonal rela-

tionships between supervisors and employees (Liden &

Maslyn 1998, Liden et al. 2008).

According to social exchange theory, employee

behaviour is influenced by the supportiveness of lead-

ers. LMX focuses on the interactions that may

develop between supervisors and individual employees

within an organisation. It seems reasonable to con-

clude that a good relationship with the supervisor (i.e.

high-quality LMX) relates to the meaningfulness of

work, as employees receive more support, could get

more interesting work and more understanding of

their role within the hospital organisation. Previous

studies have shown significant positive associations

between high-quality LMX and role clarity, organisa-

tional citizenship behaviours and job satisfaction, and

inverse associations with turnover intention (Gerstner

& Day 1997, Wayne et al. 1997, Schriesheim et al.

1999, Ilies et al. 2007, Trybou et al. 2014).

Leadership forms and transmits to employees the

mission and vision for the organisation. A key aim is

to increase the understanding of the characteristics

of good and effective health care leaders (e.g. nurs-

ing managers). Leadership has been proposed as a

significant factor for professional growth, motivation

and engagement of employees, building trust, and

developing innovative organisations (Luthans 2002,

Trybou et al. 2014). One practical implication from

the present study is that specific servant leadership

dimensions are probably useful for developing a stron-

ger exchange relationship between the leader and

health-care professionals.

Limitations and future research

The cross-sectional design of the study calls into ques-

tion any inferences one makes concerning the direction-

ality of relationships. This implies that it is difficult to

draw conclusions about the causal relationships

observed in the regression analysis. A disadvantage of

cross-sectional studies is the inability to establish tem-

poral relationship and therefore the evidence for causal-

ity can only be suggested (Rothman & Greenland

1998). On the other hand, the regression models pre-

sented in this study are based on previous conceptual

models and empirical research (Barbuto & Hayden

2011, Wu et al. 2013, Liden et al. 2014), which suggest

that the regression models presented in this study are

accurate. A future longitudinal study would be valuable

to clarify the link between servant leadership and LMX.

In order to explain the quantitative findings a mixed

method research is recommended. We think that an

embedded design with concurrent timing is appropriate.

With in-depth interviews and case studies of exemplary

servant-leaders we can seek to understand the individu-

als’ perceptions about making extra efforts to meet their

manager’s work goals (contribution), and how and in

what way individuals respect their manager’s knowl-

edge and competence (professional respect).

Second, the current study may have some degree of

common method bias. However, by using multiple

items of each dimension it reduces the effect of mea-

surement error (Kline 1998) and the dimensions used

in this study are based on previous research (Liden &

Maslyn 1998, van Dierendonck & Nuijten 2011).

Also, construct validity tests in previous studies indi-

cate that common method bias is not expected to be a

significant problem when dealing with servant leader-

ship and LMX dimensions (Wu et al. 2013).

Third, in the present as well as in previous studies,

LMX have mostly been measured by taking only the

employee (follower) perspective. LMX was measured

by employees’ overall perceptions of the quality of

their relationship with a given leader (supervisor).

This may be a weakness, but previous studies show

that LMX agreement (i.e. the extent to which leader

and employee ratings of LMX are intercorrelated) are

rather low (Gerstner & Day 1997). It seems that

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employee and leader perspectives measure different

aspects of the relationship. In the present study, focus

was upon employees’ overall perceptions as regards

social exchange relationships.

Fourth, although this study was conducted in four

health-care units it should be acknowledged that the

generalisability of the current study may be limited.

The results may be culture specific. Therefore, it is

suggested that future studies should investigate the

importance of servant leadership dimensions on LMX

across a broad range of health-care organisations in

other cultures and countries and among a broad range

of employee groups.

Implications for nursing management

The results support the significance of a management

encouraging health-care professionals to use their tal-

ents, come up with new ideas, and to solve problems.

The results also deliver support for a management

offering health-care professionals sufficient opportuni-

ties to learn new skills (empowerment) and a manage-

ment learning from criticism and admitting mistakes

(humility). Moreover, the results support a long-term

management vision emphasising the societal responsi-

bility within their organisation (stewardship).

Additionally, in health-care professional organisa-

tions research activities are highly valued and nurses are

actively encouraged to participate. However, participat-

ing in research activities is difficult to justify for many

nurses. A number of organisational barriers impede

participation, including limited resources, lack of skills

and research knowledge, and a culture of individualism.

Servant leadership is a service-oriented approach that

focuses on valuing, supporting and developing people.

Servant leaders want to bring out the best among the

employees (e.g. nurses) and the community, and there-

fore servant leaders ordinarily have a good understand-

ing about the importance of nurses participating in

research and quality improvement activities.

Acknowledgements

The authors would like to thank the participating

health-care professionals and our collaborators at the

hospital units.

Source of funding

Financial support for this research was provided by

AFA Insurance (registration number 100063) and

Region V€astra G€otaland in Sweden.

Ethical approval

A research application was submitted to AFA Insur-

ance in Sweden (registration number 100063). The

review board at AFA Insurance has approved the pro-

ject without any further ethical examination. We have

followed The Swedish Research Council (2012) guide-

lines, ethics codes (e.g. informed consent) and laws

that regulate ethical demands on the research process.

No sensitive individual data were included in the pres-

ent study (there were no data collected regarding indi-

viduals’ ethnicity, race, sexual life/orientation, or

political opinions, religious or similar beliefs). Oral

and written information was given regarding the main

aim of the study and that the study would follow

research guidelines of confidentiality. The participa-

tion was voluntary and the subjects answered the

questionnaire anonymously.

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