Servant Leadership , Employee Satisfaction , and Organizational Performance in Rural Community Hospitals

Servant leadership in today’s healthcare settings provides a unique avenue through which to assess leadership behaviors and the relationship to employee satisfaction and healthcare patient satisfaction measures. This study sought to determine the degree that leaders in community hospitals were perceived as servant leaders and the level of employee satisfaction at these rural community hospitals. Two hundred nineteen surveys were completed from 10 community hospitals. This research revealed that servant leadership and employee satisfaction are strongly correlated. In addition, servant leadership has a significant correlation between intrinsic satisfaction and HCAHPS scores. Further research can be extended to additional categories and geographic areas of the United States to determine how servant leadership, employee satisfaction, and HCAHPS are related. Hospital administrators should examine the findings of this study for possible implications to their leadership style and practice in determining how it may impact the organization they lead.


Introduction
Leaders responsible for managing today's healthcare organizations are exposed to the needs of clients, and the limitations and demands of the organizations that they must serve.These leaders must practice effective servant leadership to succeed in today's challenging climate and to balance these competing demands.Greenleaf (1977), the developer of the modern context of servant leadership, suggests that managing the institutions that care for others has transitioned from managing through personal involvement to becoming something that is mediated by an organization and its stakeholders.These organizations are often enormous, complex, powerful, impersonal, and even incompetent at times.The current climate in many healthcare organizations does not align with the idea of servant leadership, as envisioned by Robert Greenleaf, when he originally introduced the concept of servant leadership.He envisioned a model of leadership rooted in the fundamental human drive to care for others and contribute to the betterment of society.Greenleaf (1977) argued that true leadership is essentially synonymous with service and great leaders are identified by the service they perform for individuals and society.
Servant leadership behaviors appears to be what healthcare organizations need to effectively lead their organizations in today's challenging times.Bennis and Nanus (1985) stated, "The problem with many organizations, and especially the ones that are failing, is that they have the tendency to be over managed and under led" (p.21).They found that there is a difference in leadership and management, but both are important to the success of organizations.However, the distinct difference between leadership and management was matter of perspective.Leaders were vision, judgment, and effectiveness oriented, while managers were more concerned with efficiency and mastering routines or doing things right.
The purpose of this research is to assess servant leadership behaviors of leaders in today's rural community hospital industry and its impact on employee satisfaction and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.The population for this study is rural community hospitals in the United States.The study will address the following research questions: Research Question 1: To what degree are leaders in rural community hospitals servant leaders?Research Question 2: What is the level of employee satisfaction in rural community hospitals?
Research Question 3: What is the relationship between servant leadership, employee satisfaction, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores?

Servant Leadership
Leadership is an area of research which has been extensively examined over the past 30 years; however, an emerging leadership focus since 2004 has been servant leadership.Robert Greenleaf defined servant leadership in the 1970's as not just a management technique, but as a way of life which begins with "the natural feeling that one wants to serve, to serve first" (Parris & Peachey, 2013).Since Greenleaf's foundational essay The Servant as Leader (1970), research has developed to better understand the tenants of servant leadership.However, significant research contributing to an increased awareness of servant leadership did not occur until 2004.The model for servant leadership, where it has been implemented, has significant implications for the individual and the organization as a whole (Guillaume, Honeycutt, & Cleveland, 2012).According to the Greenleaf Center (2011), over 20% of the Fortune magazine top 100 companies have sought guidance from the Greenleaf Center for Servant Leadership, including Starbuck's, Vanguard Investment Group, and Southwest Airlines, among many other organizations (Parris & Peachey, 2013).
As organizations move away from the traditional command and control approach to management, a new and emerging style of leadership has surfaced, namely servant leadership.Yet, because of relatively recent timeline and amount of research data available, much research has been conducted on the theoretical approach and on developing measurement tools through which to explore servant leadership within organizations.With regard to specific research on the extent of servant leadership in the literature, servant literature research (SLR) had its origin in the medical, health care, and policy fields used primarily to make clinical and policy decisions (Paris, 2013).A practical construct of servant leadership was needed to operationalize a model of servant leadership for empirical research that would stand apart from other models of leadership (Huckabee, 2008).Barbuto and Wheeler (2006) developed an instrument through which to operationalize and measure five factors derived from characteristics deemed to be indicative of servant leadership.The Servant Leadership Questionnaire measures five factors, including altruistic healing, emotional healing, wisdom, persuasive mapping, and organizational stewardship.A description of each of the five factors, as explained by Barbuto and Wheeler, demonstrates how each of the five factors determines the extent to which leaders demonstrate their skills in each of the five subscales.Servant leaders create serving relationships with their followers, unlike transformational leaders who focus on transcending followers' self-interest toward organizational goals.
Altruistic healing (AH) measures the level to which a leader seeks to make a positive impact in the lives' of others.From the perspective of servant leadership, the goal is to serve others, therefore leaders who are high in this attribute will focus on the interests of others before their own interests and in the process work towards meeting the needs of others.Another significant component of this factor has been described as a generosity of the spirit consistent with a philanthropic purpose in life (Barbuto & Wheeler, 2006).
Emotional healing (EH) assesses the leader's commitment to and the skill in developing spiritual recovery from either hardship or trauma.Those leaders who score high in this category display such traits as empathy and strong listening skills.Both of these traits serve to facilitate the healing process by creating an environment which provides a space through which employees feel safe to share personal and professional concerns.Wisdom (W) includes a combination of awareness of one's workplace surroundings and the ability to anticipate consequences within the dynamic of the workplace.A factor in this intuitive based skill is the ability to understand organizational dynamics and connect reasonable outcomes based upon the environmental cues that they read.
Persuasive mapping (PM) describes the leaders who can influence others.Specifically, this factor encompasses the leader who can use reasoning processes and conceptual frameworks in influencing others.Considered high in the ability to earn buy-in for organizational visionary aspirations, these leaders can communicate the reasons that others should support the organizational goals.
Organizational stewardship (OS) addresses the interconnectedness that an organization has to making a positive contribution to society.Founded on the premise of ethics and value-orientation, this factor is evidenced by the extent that a leader prepares an organization to be involved in community development, programs and community outreach (Melchar, 2010).Although focused in the works performed in society, this factor recognizes the importance of developing an internal community spirit workplace through which to engage in societal organizations outside the organization.

Job Satisfaction
The term "job satisfaction" reflects a person's attitude towards their job and the organization and can be defined as an employee's emotional reaction towards their work environment based on the evaluation of the actual results against their expectations (Phillips & Gully, 2012).Saari and Judge (2004) found evidence that job satisfaction is a predictor of employee performance and the relationship is stronger for professional jobs.Effectively managing the variables that influence employee behavior and job satisfaction affects their discretionary efforts and performance levels (Phillips & Gully, 2012).Stringer (2006) found empirical support for the proposition that high-quality supervisor-employee relationships are positively related to levels of both intrinsic and extrinsic job satisfaction.Mohammad, Al-Zeaud, & Batayneney (2011) also found that a significant link exists between leadership behavior and job satisfaction.
The intrinsic component of job satisfaction is dependent on the individual's personal perception and emotional state regarding the work environment and includes factors such as recognition, advancement, and responsibility.The extrinsic components are comprised of external job related variables that would include salary, supervision, and working conditions, (Negussie & Demissie, 2013).Randolph (2005), in a survey of Physical Therapists, Occupational Therapists, and Speech Language Pathologists, revealed that intrinsic factors, rather than extrinsic factors such as pay, tend to be predictive of career satisfaction and desire to stay on the job.Mohammad et al. (2011) explored the relationship between transformational leadership and job satisfaction of Jordanian registered nurses at private hospitals.The results of the study indicated the statistically strongest significant positive relationship to exist between intrinsic job satisfaction and the variables of intellectual stimulation and inspirational motivation.Intellectual stimulation was described as the employee's empowerment to solve problems and challenges whereas inspirational motivation refers to the leaders' commitment and ability to build relationships with their staff to achieve a common vision and set of goals.Both intellectual stimulation and inspirational motivation are considered main staples of Greenleaf's servant leadership style.

Servant Leadership and Job Satisfaction
Servant leadership is centered on the core values of "caring" and "serving others," and focuses on the values of trust, appreciation of others, and empowerment (Hoveida, Salari, & Asemi, 2011).The servant leader leads by example and, as such, enables and empowers the follower with all the tools necessary to succeed.This modus operandi of genuine caring and authenticity for the needs of others has led to improved organizational effectiveness.The same characteristics lend the servant leadership model to be considered the most appropriate leadership style for increased organizational performance and enhanced employee satisfaction through improved focus on the customer (Jones, 2012b).
Various studies support the thesis that servant leadership positively affects employee behavior.Netemeyer, Maxham, and Pullig (2005) found servant leadership to motivate the employee to go above and beyond the basic requirements of the job responsibilities in their interaction with customers.Walumbwa, Hartnell, and Oke (2010) point out that servant leadership is conducive to molding positive employee attitudes as well as creating work environments that promote benefits for both individuals and the work group.Studies by Johns (2006) and Ehrhart (2004) further indicate a strong relationship to exist between leaders and followers with the significant benefit of increased organizational effectiveness.In addition, servant leadership possesses a significant positive correlation with employee satisfaction (85%) and with employee loyalty (79%) (Donghong, Lu, & Lu, 2012).Employee satisfaction and organizational commitment are key elements in determining organizational performance and effectiveness (Rehman, 2012).

Servant Leadership, Job Satisfaction and Customer Satisfaction
The federal government expressed their vision or health care in a "triple aim" format: improving the individual experience of care; improving the health of the populations; and reducing the per capita cost of care (Berwick, 2008).The main driving force of any business is the quality of the product or service rendered.In the health care sector, the creation of value is measured by the outcomes achieved, not the volume of services delivered.Shifting focus to the quality in the healthcare delivery system therefore, remains the central challenge (Porter, 2010).Hence, the most fundamentally basic and critical responsibility for health care leaders is to understand their customers and provide the best care possible (Capoccia & Abeles, 2006;Porter, 2010).
Harold McDowell, CEO of TD Industries, an ardent supporter of servant leadership practices, makes a very valid point with his statement, "People go to work for a great company but quit for a bad supervisor no matter how great the company is" (as cited in Faloon, 2011, p. 32).The World Health Report lists unmotivated healthcare workers as one of the top ten leading causes of inefficiencies of health care system (World Health Organization, 2006).
Research data support the hypothesis that the level of commitment correlates positively with organizational performance, and employee commitment mediates the relationship between leadership style and organizational performance (Khan, et al., 2012).Schneider and George (2011) support these findings as it pertains to the correlation between leadership patterns and influence on organizational workings, employee satisfaction, or lack thereof, and its impact on employee turnover.This relationship is exemplified in the quality of the organizational performance, job performance, organizational citizenship, absenteeism, turnovers, and tardiness (Kool & Dierendonck, 2012).Consequently, leadership should be considered a determinant variable in organizational behavior.Research further found that servant leadership impacted the employer-employee relationship to the extent that it reduced levels of job stress, elevated levels of job satisfaction, and solicited greater organizational commitment from the employee base (Franke & Park, 2006;Hoveida, et al., 2011).
According to Waterman (2011) servant leadership is characterized by the mantra of putting other people first.Adopting this caring, empathic attitude should not only be displayed towards patients and customers but also should be applied in the work place and surrounding community (Waterman, 2011).There is ample evidence for the need to respect and develop the frontline workers (Abeles, 2006).Bodur (2002) discovered in his analysis of job satisfaction that a close correlation exists between job satisfaction and quality of health care.The nature of servant leadership, putting other people first, and displaying concern and empathy for others, lends itself to be the preferred vehicle to engage healthcare employees into caring for their customers or patients.Servant leadership not only is designed to create a trusting, fair, collaborative, helping culture resulting in greater individual and or organizational effectiveness, but also supports and promotes the followers well-being, whether staff members or patients (Parris & Peachey, 2013).
Practicing servant leadership encompasses three dimensions: motives, means, ends or outcomes.Servant leadership further embraces the "triple bottom line" (sustaining people, profit and the planet) and does practice moral symmetry to balance the needs of all affected (SanFacon & Spears, 2010).Servant leadership affects are closely linked to employee satisfaction and organizational profits as various studies have alluded to a direct causal relationship between leadership and customer satisfaction, employee satisfaction, and financial performance (Khan, et al., 2012;Jones, 2012b;Obiwuru, Okwu, Akpa, & Nwankere, 2011).

Research Methodology
This section presents the research methodology utilized by this study.We describe the sample used, and then discuss how each of the variables included in the study are operationalized and presented for statistical analysis.

Target Population and Sample
The participants in this study were employees from ten community hospitals located in the southeastern region of the United States.Survey data was collected in December 2013 and January 2014.While a copy of the final research paper and research data were made available to the hospitals, no identifiable information was made available about the participants to ensure privacy of participants.
There were 3,942 surveys mailed to hospitals and then delivered to all employees with their payroll stubs inviting hospital employees to an online survey.One reminder invitation note was sent to employees at about the mid-point of the survey.Two hundred and nineteen usable surveys were completed online returning a response rate of 5.6%, during the two month time the survey remained open.The summary of the demographic results are found in Table 1. ) indicated taking some college to a master's degree, and 11 (5%) had earned greater than a master's degree.Forty-nine (24.4%) of respondents identified themselves as male and 170 (76.6%) as female.Sixty-five (29.7%) of respondents identified themselves with 10 years or less work experience, 108 (49.3%) identified that they had more than ten years and less than thirty years work experience.Eighty-five (38.8%) respondents indicated that they made less than $50,000 per year, and 134 (61.2%) make more than $50,000 per year.

Instrumentation
The survey consisted of three parts.Part one of the survey was developed to obtain demographic information that included age, education, gender, work experience, and income.Part two of the survey utilized the Servant Leadership Questionnaire (SLQ) created by Barbuto and Wheeler (2006) and adapted to measure the degree of servant leadership categorized by five factors: altruistic healing, emotional healing, wisdom, persuasive mapping, and organizational stewardship.This research utilized the self-rater version of the SLQ reliabilities ranging from .68 to .87.Self-rated subscale means ranging from 2.48 to 2.98, with fairly consistent standard deviations ranging from 0.49 to 0.58.In the self-rater form wisdom and organizational stewardship were the highest reported characteristics for Barbuto and Wheeler (2006).There were 23 questions that measured the five factors of servant leadership using a five-point Likert scales as a way for participants to record their responses.The possible responses included 1 = not at all, 2 = means once in a while, 3 = sometimes, 4 = fairly often, 5 = frequently.
Part three of the survey employed the Minnesota Satisfaction Questionnaire (MSQ) (short-form) developed by (Weiss, Dawis, England, and Lofquist, 1967).The MSQ measures two subscales of job satisfaction: intrinsic and extrinsic, and also measures general satisfaction, which is a summary of both scale questions.There were 20 questions that measured the two sub-factors of job satisfaction and total general satisfaction using a five-point Likert scale as a means for participants to report their responses.The possible responses were: 1 = very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, and 5 = very satisfied.

HCAHPS
In addition to the survey components of demographics, servant leadership, and the employee satisfaction concept it was important to consider customer and patient satisfaction.Khan, Hafeez, Rizvi, Hasnain, and Marian (2012), argued that customer or patient satisfaction is widely known and accepted to be one of the most significant factors of any business success.Patients represent the customer base for the hospital industry, and the perception of their experience of care drives organizational performance.Lutz & Root (2007)confirm that the perception of the quality of care directly impacts patient satisfaction and the probability of repeat business.
In response to the care discrepancies noted among hospitals, federal policy makers implemented the HCAHPS program designed to provide a national portrait of patient care experiences and improve accountability in US hospitals (Ashish, 2008).The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) was developed by the Agency for Healthcare Research and Quality (AHRQ) for the Centers of Medicare and Medicaid Services (CMS) with the intent to provide a standardized data collection tool to measure a patient's perspective of their hospital care (HCAHPS: Patients' perspectives of care survey., 2013).The goal of the public reporting instrument is to provide patients with quarterly data and information that might be helpful in selecting an appropriate hospital.The HCAHPS survey is composed of 27 items, 18 of which entail critical aspects of their hospital care (communication with physicians and nurses, responsiveness of staff, cleanliness, quietness, pain management, medication management, discharge planning, overall rating, and recommendation of hospital), four items direct patients to appropriate questions, three items to adjust for the patient mix across hospitals, and two to support congressional mandated reports.Eligibility criteria for patient participation include at least one overnight stay as an inpatient, over the age of 18 at time of admission, non-psychiatric MS-DRG/principal diagnosis at discharge, and being alive at time of discharge.Even though reporting is on a voluntary basis, the program links a portion of the hospital performance on a set of quality measures to the Inpatient Prospective Payment System (IPPS) (HCAHPS Fact Sheet, 2012).Therefore healthcare organizations do have a financial stake in reporting and maintaining high quality HCAPHS data.The significance of achieving high scores on the HCAHPS surveys and its related impact on the success of the hospital is further underscored by the percentage of time administrators spent on servant leadership behaviors (Artrip, 2013).
HCAHPS scores were gathered by the authors from the Medicare website for comparison purposes in this study and inclusion as a continuous variable.According to HCAHPS Fact Sheet ( 2012), the CAHPS® Hospital Survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care.HCAHPS is a 27-item survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience.Even though many hospitals collect information on patient satisfaction for internal use, until the development of HCAHPS there were no common metrics or national standards for collecting and publicly reporting information about patient experience of care.HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally, since 2008.
The researchers utilized results from one critical question on the HCAHPS survey, Question 22, "Would you recommend this hospital to your friends and family?"The question offers four answers: 1. Definitely No, 2. Probably No, 3. Probably Yes, and 4. Definitely Yes.For the purpose of this research the focus was placed on option number 4. Definitely Yes, and the percentage of those patients who would recommend the hospital based on their recent visit and perceptions of satisfaction with the experience (HCAHPS Survey, 2014).

Data Analysis
The data were entered and analyzed by the Statistical Package for the Social Science (SPSS) for Windows, version 19.0.Prior to statistical analyses, data cleaning and handling of missing values were performed.
Frequency distributions of all the variables were checked for outliers, missing data, and errors.Normal distributions of the dependent and independent variables were reviewed.
Analyses of the summary statistics were performed that computed the means, standard deviations, frequency counts, and percentage of demographic data.Mean scores and standard deviations were computed for the three factors of satisfaction and five factors of servant leadership to answer research questions one, two, and three.
Pearson r correlation was used to answer research question three in this study.It was used to examine significant relationships between the continuous variables of the five subscales of servant leadership and hospital employee satisfaction levels.Pearson r is the linear correlation between two variables X and Y, providing a value between +1 and −1.One is total positive correlation, 0 is no correlation, and negative one is total negative correlation.An alpha level of .05level of confidence for statistical tests was set in SPSS 19.0 for Windows software.
The Multivariate Analysis of Variance (MANOVA) was utilized for a direct test of "no relationship" versus "there is a relationship" with respect to the dependent variables in the analysis.In MANOVA, a linear function (y) of the dependent variables (servant leadership subscales, three satisfaction scales, and the HCAHP score) in the analysis is constructed, so that "inter-group differences" on y are maximized.The composite variable y is then considered in a manner similar to the dependent variable in a univariate ANOVA, in which the null hypotheses is accepted or rejected.Alpha was set at .05 level of confidence.
The study addressed the following questions: 1).To what degree are leaders in rural community hospitals servant leaders?2).What is the level of employee satisfaction in rural community hospitals?3. What is the relationship between servant leadership, employee satisfaction, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores?

Analysis of Research Questions and Discussion
1).To what degree are leaders in rural community hospitals servant leaders?
Descriptive statistics were used to determine the degree to which leaders in rural community hospitals are servant leaders.Table 2 presents the summary statistics from the SLQ.The mean score of all item subscales was 3.28 (SD=1.48)with the item mean ranging from 2.91 (SD=1.52)and 3.59 (SD=1.35).These results indicate that supervisor behavior ranges between sometimes behaving as a servant leader role to behaving this way often.
Results indicated that hospital workers perceived higher mean scores in the subscales of organizational stewardship 3.59 (SD=1.35)and wisdom 3.51 (SD=1.35).Note.SLQ Key-Describes the behavior of the immediate supervisor as perceived by the employee: "1" means not at all (supervisor does not behave in this manner); "2" means once in a while (supervisor behaves in this manner-once in a while); "3" sometimes (supervisor behaves this way-sometimes); "4" fairly often (supervisor behaves this way-often); "5" frequently, if not always (supervisor typically behaves in this manner).
2).What is the level of employee satisfaction in rural community hospitals?
Descriptive statistics were used to determine the employee satisfaction in rural community hospitals.Table (3) presents the mean scores and standard deviations for each of the three scales of satisfaction as measured by the MSQ and the five subscales of the SLQ.Hospital workers had a higher mean score on subscale extrinsic satisfaction 3.52 (SD=1.29)than intrinsic satisfaction 3.30 (SD=1.40).General satisfaction is a summary of all satisfaction scores from intrinsic and extrinsic, plus additional questions 3.64 (SD=1.18).Results indicate that rural hospital worker's general satisfaction is slightly closer to satisfied than neutral-neither satisfied nor dissatisfied.Note.MSQ Key: "1" very dissatisfied; "2" dissatisfied; "3" neutral-neither satisfied or dissatisfied; "4" satisfied; "5" very satisfied.
3).What is the relationship between servant leadership, employee satisfaction, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores?
The Pearson r correlation was computed to determine significant relationships between the continuous variables of the five subscales of servant leadership and the three satisfaction scales (see Table 4).The correlation coefficients were significant for all of the five subscales of servant leadership and hospital workers job satisfaction levels at the 0.01 level of significance (.two-tailed).Results indicate that all of the servant leadership subscales except altruistic healing have a significant correlation with extrinsic satisfaction and HCAHPS.These results indicate support of a hypothesis that there is a relationship between servant leadership, extrinsic satisfaction, and HCAHPS.Results also indicate a correlation between two out of the five servant leadership subscales and intrinsic satisfaction.In addition, general satisfaction, and persuasive mapping, and HCAHPS have a correlation.However, intrinsic satisfaction and general satisfaction, overall, do not support the hypothesis that there is a significant relationship between servant leadership, satisfaction, and HCAHPS scores.

Conclusions and Recommendations
Scruggs-Garber, Madigan, Click, and Fitzpatrick (2009) consider Greenleaf's servant leadership to be the most effective leadership model to address the challenges that face the health-care industry.The healthcare industry by nature serves and cares for people, and in such capacity, is the ideal platform to adopt and incorporate servant leadership (Scruggs-Garber, 2009).The "servant leader" model centers around identifying and addressing the requirements of followers ahead of individual considerations, ultimately, leading to the development and growth of the follower as opposed to the needs of the manager or the organization (Jones, 2012a).It is further characterized by the key qualities for being a good listener, self-awareness, empathy and stewardship, which enable the leader to better understand their constituent's needs and maximize their potential, while tailoring their aspirations to the organizational needs and objectives.
Servant leaders should therefore be viewed as trustees of the human capital of an organization (Berendt, 2012).Jones (2012b) investigated the effects of servant leadership on the leader-follower relationship and the resulting impact on the customer focus within the framework of employee satisfaction, empowerment, organizational culture, and performance.The results of his study indicate that employing servant leadership is conducive to greater organizational productivity and increased fiscal stability.He further concluded that the increased profits occurred as a net effect of servant leadership as mediated through improved job satisfaction, a reduction in employee turnover, and a greater focus on the customer.Mayer, Bardes, and Piccolo (2008) echoed the sentiment that increased employee performance leads to greater customer focus when an employee views their manager to exhibit servant leadership skills.
This study empirically assesses servant leadership, employee satisfaction, and their relationship to HCAHPS scores, which is a measure of patient satisfaction.Through this research it has been acknowledged that servant leadership and employee satisfaction are strongly correlated and findings are consistent with (Jones, 2012b;Phillips & Gully, 2012;Mohammad, Al Zeaud, & Batayneay, 2011;Stringer, 2006).In addition, servant leadership has a significant correlation with extrinsic employee satisfaction and HCAHPS.There is also a significant correlation between intrinsic satisfaction and a number of servant leadership subscales findings consistent with (Stringer, 2006).
General satisfaction, persuasive mapping (a subscale of servant leadership), and HCAHPS have a significant positive correlation.However, the employee satisfaction subscales of intrinsic and general satisfaction are not significantly correlated to servant leadership and HCAHPS scores.Leadership is important in any organization and this study highlights the important relationships between servant leadership, employee satisfaction, and HCAHPS.Managers have the opportunity to enhance their relationships with employees through servant leadership, and improve customer satisfaction HCAHPS scores for the improvement of their organizations.

Limitations and Future Research
There are a number of limitations to this study, and one is that it cannot be generalized to all rural community hospitals and hospitals in the United States due to limited geographic sampling and limited sample conducted in this study.Further research can be extended to additional categories and geographic areas of the United States to determine how servant leadership, employee satisfaction, and HCAHPS are related.Managers and leaders of United States hospitals can benefit from this study.According to the Garman & Lemak (2011) and the American College of Healthcare Executives (2012) the challenges that healthcare managers face are financial, quality, and compliance issues.Healthcare manager objectives are to achieve high patient satisfaction and maximize profitability by using the leadership style that best allows them to achieve these objectives.
Further research of this topic should use a mixed methodology that incorporates qualitative and quantitative methods.A longitudinal study could also provide data as the landscape of healthcare industry and legislations is in constant flux.A future study should correlate more of the HCAHPS scores along with servant leadership and employees' satisfaction scores.Hospital administrators should examine the findings of this study for possible implications to their leadership style and practice and how it may impact the organization that they lead.

Table 1 .
Summary of the sample demographic characteristics (n=219)

Table 2 .
Summary statistics of the total subscale scores of the SLQ (N=219)

Table 3 .
Summary statistics of the total subscale scores of the MSQ (N=219)

Table 4 .
Pearson's r correlation between servant leadership and job satisfactionThe servant leadership subscale intrinsic satisfaction, emotional healing, and HCAHPS, at a value of .407,F (2, 7) = 2.401, is significant at 0.061, is notable just outside the P < 0.05 (2-tailed) range of correlation.In addition, the servant leadership scale persuasive mapping, general satisfaction, and HCAHPS, at a value of .529,F (2, 7) = 3.932, is significant at 0.072, is notable falling just outside the P < 0.05 (2-tailed) range of correlation.