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Department: Performance Potential

Relational proficiency

What it is and why it matters

Koloroutis, Mary MSN

Author Information
Nursing Management (Springhouse): May 2020 - Volume 51 - Issue 5 - p 52-54
doi: 10.1097/01.NUMA.0000659444.30746.3e
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Healthcare leaders have an extraordinary challenge to provide leadership for professionals who are literally responsible for making life-and-death decisions and caring for people in the face of complex and high-stress environments. Relational proficiency is an essential ingredient for leaders to be successful. Although much has been written about the importance of quality relationships in healthcare, very little has been written about how to make quality relationship happen.

This article describes what it takes for leaders to consistently convey interest in and openness to the lived experience of their teams and cultivate compassionate connections with their teams in the same way they want their teams to create compassionate connections with the patients and families in their care.

Four relational practices

By putting language to how and why connections happen, clinicians in all disciplines and leaders at all levels can demystify what constitutes healthy interactions. The four relational practices that reliably make human connections happen are attuning, wondering, following, and holding.1 These practices can be learned, reflected upon, practiced, and mastered. Although identified specifically to support and improve therapeutic relationships with patients, these practices are presented here in terms of leadership.

Attuning. Relationally competent leaders tune into individuals, teams, and situations by bringing their full presence and attention to them. Attuning is a way of being intentionally present that conveys openness and interest. It requires listening, seeing, and noticing both verbal and nonverbal cues. Attuning to someone is an act of valuing, respecting, and acknowledging the importance of the person. When leaders attune, those they lead feel seen. Attuned leaders cultivate a culture of psychological safety.

Wondering. Relationally competent leaders are genuinely interested in and curious about others. They're open to what can be learned about each individual while intentionally suspending assumptions and judgments. These leaders ask open-ended questions and suspend their own agendas. The conscious decision to wonder prevents them from judging too quickly. Wondering helps leaders assume good intent about people, particularly in times of upheaval or confusion. When leaders wonder, they remain open to new information, which improves decision-making.

Following. Relationally competent leaders focus on what another person is teaching them about what matters most to him or her. Leaders allow that information to guide their interactions and leadership. This requires focusing on what the person is telling or showing them and responding to cues and preferences. Relationally competent leaders listen, consciously avoid interrupting, and validate what they've heard. And they explore areas of disagreement with curiosity and respect.

Holding. Relationally competent leaders skillfully care for and create emotional safety and dignity for individuals and teams. This requires them to follow through on commitments and provide support for their teams to meet expectations, achieve goals, and take risks without fear of being hung out to dry. Relationally competent leaders actively cultivate a culture in which the individuals who are focused on caring for patients feel cared for. They remain a steady presence in the face of strong emotions and express appreciation for the work of their teams.2

Lead effectively

Relational proficiency is the social and/or professional knowledge and skill set shared by people who attune, wonder, follow, and hold in most of their interactions. No one does all four relational practices always, and the aim isn't to do all of them perfectly. In practice, mastery of the four practices is a lifelong quest marked by continual insights, learning, and course correction. The pursuit of relational proficiency is a noble aim, just cause, and infinite journey in which we continuously grow, deepen our understanding of ourselves, and improve our relationships with others.

The definitions of attuning, wondering, following, and holding give you an introduction of what goes into relational proficiency for leaders. Further work has also been done on the four practices, out of which has emerged a collection of behaviors that allow leaders to advance their own development, as well as mentor other leaders.

A leader who attunes:

  • cares for his or her own energy, establishes effective boundaries, and is proactive about the best use of time
  • is intentional about forming connections with others and being present with them
  • is aware of the effect of his or her own presence and energy on the group's well-being and intentional about bringing positive and focused energy
  • communicates acceptance and respect for team members through listening, spoken words, and body language
  • gives focused attention to people during interactions
  • recognizes the potential for technology to interfere with focus and attention during interactions with individuals and groups and manages this appropriately
  • recognizes and invites input from people who may feel least influential and/or underrepresented within the group/organization
  • is aware of signs of moral distress and compassion fatigue and takes action to address and/or prevent them.

A leader who wonders:

  • stays open and curious during interactions, taking care not to reach conclusions too quickly
  • asks trusted others for feedback relative to his or her own leadership effectiveness
  • suspends his or her own agenda as appropriate and seeks to learn about other people and what's important to them
  • remembers that everyone has a unique backstory that affects their interactions, actions, and responses
  • avoids assumptions, consciously suspends judgments, and is aware of the potential for personal bias
  • regularly uses open-ended questions to invite people to speak openly about what's important to them and listens with interest
  • demonstrates an openness and desire to listen and learn
  • conveys interest in and respect for human diversity and differing perspectives.

A leader who follows:

  • listens closely to people, watching for nonverbal cues and asking questions to better understand their perspectives
  • refrains from interrupting, correcting, or rushing to fix things before hearing the other person's perspective
  • actively clarifies and seeks to resolve areas of concern and/or disagreement
  • builds a sense of safety and trust by listening to and remembering what team members say they need
  • provides sufficient time and attention for team members to share what's important to them
  • collaborates with team members as involved partners in the success of the work.

A leader who holds:

  • acts with integrity and care by following through on all commitments
  • shares information proactively so the team is informed and clear about their direction, especially in times of change
  • remains a steady presence, even in the face of strong emotions
  • demonstrates emotional composure when faced with crisis or rapid change
  • genuinely values all people for their contributions and their unique capabilities
  • avoids derogatory labels or descriptors that may bias team members and interfere with their ability to work together effectively
  • uses meetings as a means for engaging the team and inspiring energy to overcome challenges
  • addresses emotionally difficult situations directly, promptly, and honestly
  • models and fosters self-awareness and self-compassion as foundational to compassionate care
  • expects respect and civility from others and treats others with respect and civility
  • addresses any signs of bullying or workplace hostility to ensure a safe and compassionate culture.3

Reaching full potential

Your work as a healthcare leader has the capacity to create the conditions for your team to reach its full potential. For this to happen, you need to clearly articulate expectations for excellence in practice, as well as expectations for healthy and respectful team relationships. Leaders serve as standard bearers for excellence, which means investing time in staff development, mentoring, and coaching. It means recognizing and appreciating the work of human caring and supporting your team during times of both struggle and achievement. All of these actions require relational proficiency.

As a leader, you're called on to be fearless and courageous. Your voice is crucial for safeguarding humane and compassionate care for your patients and ensuring optimal working conditions for your staff. You must understand clinical complexities and ethics, business trends and implications, and how to be a skilled negotiator and communicator. The work is big and meaningful, and you can't do it alone. Embracing your own imperfections with humility is fundamental to navigating the complex territory of leading patient care. To achieve this, you need to cultivate a community of supportive colleagues in which you can come together to share your struggles, celebrate successes, learn new ways of being and doing, and encourage others. These things also require relational proficiency.

Finally, as a healthcare leader, it's essential that you care for your own well-being. You can't lead with the creativity and endurance your work requires without first caring for yourself. Although this sounds simple, we all know that it may be the biggest challenge of all, which brings us to the most important foundation for relational proficiency—having a healthy, loving relationship with yourself. As Long and Smith wrote, “If you want the world to feel safe and loving for those in your care, we invite you to start by making your own interior world a safer and more loving place for you.”4

A valuable skill set

The value of relational proficiency in leaders can't be overstated. In our complex healthcare world, it's a given that there will always be too many things on which to focus and myriad demands to balance. An important leadership principle is knowing that you can't focus people on improving metrics and expect relationships to improve as a byproduct. But you can focus people on improving relationships and expect quality, safety, patient experience, employee engagement, and the bottom line to improve.2 When you focus people on quality relationships, you'll cultivate a flourishing and healing culture.


1. Koloroutis M, Trout M. See Me as a Person: Creating Therapeutic Relationships with Patients and Their Families. Minneapolis, MN: Creative Health Care Management; 2012.
2. Koloroutis M, Wessel, Smith R. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2020.
3. Creative Health Care Management. Leader insights. 2018.
4. Long B, Smith R. Attuning, wondering, following, and holding as self-care. In: Koloroutis M, Abelson D, eds. Advancing Relationship-Based Cultures. Minneapolis, MN: Creative Health Care Management; 2017.
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