Eloise Balasco Cathcart is a clinical associate professor and the coordinator of the Nursing Administration master's program at New York University College of Nursing in New York, N.Y.
The author has disclosed that she has no financial relationships related to this article.
Contemporary healthcare organizations require nurse executives who can manage complexity, uncertainty, and increased transparency while ensuring that patients and families receive the care they need in ways that address their concerns.1 To be successful as leaders of both the discipline and the organization, nurse executives need sophisticated frontline managers who have the knowledge and skill to translate this demanding agenda into everyday practice. Relational work has emerged as a key domain in nurse manager narratives of best practice, and expertise in this core leadership skill is what allows our nurse managers to venture into unknown territory and ensure positive outcomes for patients and the organization.2
Relational work is the ability to create, sustain, and effectively manage relationships with staff, patients and families, peers, interdisciplinary colleagues, and organization executives.1 It's impossible to become an expert leader without successfully mastering the skills of interpersonal engagement, and only through authentic connection can nurse managers create trust and influence clinical nurses to do the arduous work that their roles require.
Doing the work
For nurse managers, the relational skill of involvement is first and foremost a moral skill because it's directly connected to the ethical demand of nursing practice. Highly effective nurse managers' relationships with others are fueled and measured by the moral obligation to always do the right and good thing for patients, families, and staff in ways that build on strengths and respect individual concerns. The expert skill of involvement is much more than cordial conversation or making a clear distinction between self and other. To do relational work, it's necessary to be engaged in the particular situation in an open and attentive way. Only then is it possible to discern the true nature of the situation, see what's at stake, and be able to draw on relevant knowledge to respond in effective ways.
The skill of involvement is complex and demanding, requiring persistence and the ability to see the big picture, as well as the specifics of the particular situation; recognize the limits of rules when dealing with human behavior; and understand the cultural context in which the situation occurs. Managing personal anxieties is necessary to stay open to the situation without becoming overwhelmed or shutting down prematurely.
Developing the right kind and level of involvement requires experiential learning and situated coaching.3 The skill of involvement can't be learned from a book or in the classroom. Theories and evidence provide a framework for understanding human behavior and ways of dealing with human intents and responses, but theories can never prescribe the right way to respond in a particular situation with specific individuals. The manager must be able to accurately read the situation and understand the concerns of each person involved to know how to act. This kind of know-how is learned when the manager has the openness and humility to allow his or her understanding to be turned around. It requires focused attentiveness and recognition, and an environment in which reflection on experience is deliberate.
Skills of relational work
There are certain skills that are foundational to relational work. Although one can only become an expert in the skill of involvement by doing it (and having a high tolerance for imperfection at first), consider teaching your frontline managers the following points.
- Be clear about your values. What do you believe about being a leader? Why are you doing this work? The more in touch you are with your values, the easier it will be to articulate what matters to you.
- Stay open to the big picture rather than getting stuck on less important details. Your ability to grasp the essence of the situation will help you draw on the right knowledge and experience to determine the right response. Ask yourself what's at stake? What's to be gained and what's to be lost?
- Remain curious and open, and include your staff members in conversations so that you can learn from one another. As the manager, only you can create the space for this to happen. You want the solution to reflect the concerns of everyone involved so all will feel heard and respected. (See Emerging leadership models.)
- Focus on the common good. Learn to see conflict as a way to move the conversation and the practice to a higher level. Become comfortable talking about contradictions, opposite opinions, and paradoxes without denigrating the feelings of any team member.
- Manage your own anxiety or feelings of anger, disappointment, or frustration. Your behavior is your most important leadership tool and will determine, to a large extent, the tone of the conversation and how staff members respond to you and each other.
- Establish a relationship with a mentor who's committed to your success and willing to be a coach as you continue to develop your leadership practice. By routinely engaging in thoughtful dialog with an expert senior colleague, you'll learn how to identify what's salient in a particular situation, reframe issues, and imagine alternative solutions to clinical and ethical dilemmas. This coaching-in-context is necessary to foster the experiential learning required for practical wisdom to develop.
Remember that the goal is always to teach and coach staff members to practice in a better way; the best way to do this is to build on their individual and collective strengths. (See Helping new managers develop relational work skills.) The only way to be a successful leader is through the team, so it's definitely worth the investment!
Realizing the vision
Today's nurse managers are encouraged to use explicit knowledge and data that can be codified, measured, and generalized to manage risk and promote change. Relational work is often undervalued; however, nurse managers are effective only if clinical nurses trust in their competence, character, and skill to navigate the turbulent waters of an unpredictable and evolving healthcare system. Coaching nurse managers to develop relational skills is essential to their ability to be successful in their role and realize the organization's vision.
Emerging leadership models
Consider these two new models of leadership:
- organizational conversation, in which the interaction between the manager and staff members is open and fluid rather than closed and directive. Leaders talk with employees, not to them, and strategy emerges from a cross-organizational conversation.1
- teaming, in which employees become comfortable with a new way of working together based on trust and a clear articulation of values, build psychological safety, and see conflict and failure not as impediments but as propellants to the innovation and creativity needed to meet the demands of complexity and uncertainty that characterize contemporary organizations.2
1. Groysberg B, Slind M. Leadership is a conversation. Harv Bus Rev. 2012;90(6):76-84.
2. Benner P, Tanner C, Chesla C. Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. 2nd ed. New York, NY: Springer; 2009.
Helping new managers develop relational work skills
When a new manager can observe the practice of an expert and have the opportunity for mutual reflection, he or she can learn the skill of involvement in a more effective way. In the following exemplar, a graduate student describes observing her preceptor successfully manage a situation:
“I watched my preceptor work with a certified nursing assistant (CNA) who consistently comes in to work late. This CNA had already received a verbal warning and this discussion was about her work habits. As I watched my preceptor deal with this situation, I could see that she was talking with the CNA about her responsibilities to patients while trying to stay connected to her and open to the circumstances of the CNA's life.
The CNA is a single mom having difficulty finding a babysitter to watch her child. Because of this, at times, she's unable to come in to work or be here on time. My preceptor's response was that she would never expect the CNA to abandon her child or put her child at any risk. However, she needed to take care of her responsibilities at home because it was infringing on her responsibilities at work. She stated that she didn't want to pursue disciplinary action but the CNA's actions put patient safety at risk and continuing with this type of behavior could endanger her job.
The CNA's response seemed genuine and thoughtful. She appeared to understand that she had to manage her home responsibilities differently but she also understood what my preceptor was saying. She stated that she loved her job and she wouldn't want to put any patients at risk. She also stated that she would do a better job of coming to work on time and that she would like to continue working here.
I learned a lot from observing my preceptor deal with this delicate situation and from the discussion she and I had about it afterward. She didn't want to terminate this CNA's job but she did what she had to do to by bringing the situation back to the patient. It was a tough situation for the CNA to deal with, however, the nature and tone of the conversation respected the CNA's feelings and dignity. She understood the consequences of her actions and she said she would strive to do better. Only time will tell if this situation improves. It made me think a lot about how I would handle a similar situation if I were a manager.”
By watching her preceptor in this situation, the student's moral imagination was challenged to think about a more humane way to meet the demands of patient care while respecting the difficulties that this employee faced trying to manage her life as a single working mother. The student observed her preceptor hold two perspectives simultaneously—her ethical obligation to safe patient care and a genuine concern for the employee—and express clear expectations for the employee's work performance while not punishing or chastising her. Because she had the opportunity to observe this interaction, the student learned a different way to deal with an employee's performance issue than by following a disciplinary protocol designed to improve adherence to the rules. The situation offered the student a concrete way to approach a similar situation in her own leadership practice and she's more likely to remember what she learned because she observed the conversation and discussed it afterward with her preceptor.
1. Cathcart EB. The role of the chief nursing officer in leading the practice: lessons from the Benner tradition. Nurs Adm Q. 2008; 32:(2):87–91.
2. Cathcart EB, Greenspan M, Quin M. The making of a nurse manager: the role of experiential learning in leadership development. J Nurs Manage. 2010; 18:(4): 440–447.
3. Cathcart EB, Greenspan M. The role of practical wisdom in nurse manager practice: why experience matters. J Nurs Manage. 2013; 21:(7):964–970.