The Institute of Medicine's (IOM) report, The Future of Nursing: Leading Change, Advancing Health, recommends that nurses should be full partners with physicians and other healthcare professionals to lead improvement and redesign healthcare in the United States.1 The report acknowledges that nursing leadership is critical at every level during the transformation of healthcare and being a full partner requires leadership skills and competencies.1 To ensure that nurses are able to assume leadership roles, leadership-related competencies should be imbedded and promoted for nurses, at all educational levels, and across the spectrum of healthcare settings.

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With nurse staffing shortages, rising patient acuity, complex technologies, and the rapid changes in healthcare today, the system poses several leadership challenges for professional nurses who seek to meet the expectations of the IOM report.2 Improving clinical nurse work environments is a major challenge as it impacts both patient and nursing outcomes. Nursing evidence links quality-of-practice environments with decreased mortality and failure-to-rescue situations, patient safety, length of stay, patient satisfaction, and nurse satisfaction, retention, and turnover.3

At the base

To promote healthy work environments, several professional organizations, including the American Organization of Nurse Executives (AONE), the American Association of Critical-Care Nurses (AACN), and the Association of periOperative Registered Nurses, defined competencies essential to successful nursing leadership and have developed assessment tools that measure these skills and behaviors.

The vision of the AONE is to shape the future of healthcare through innovative and expert nursing leadership; this requires nurses in leadership positions to develop and maintain core nurse leader competencies.4 The AONE asserts that nurse leader competencies are relevant to all nurses in supervisory positions regardless of their education level or organizational title; leadership competencies are applicable to both current and aspiring nurse leaders in planning and preparation of career advancement.4 The IOM recommends that nursing education programs should prepare the nursing workforce across all levels to assume leadership positions.1

One way to prepare leaders is through the nursing leadership competencies of communication and relationship building. According to the AONE, communication and relationship competencies include effective communication, relationship management, influence of behaviors, ability to work with diversity, shared decision making, community involvement, medical staff relationships, and academic relationships.4

Competency in communication and relationship management examines how leaders understand the people they work with and how they use that knowledge to effectively build relationships.5 Leaders build quality working relationships that are characterized by trust, expectations, and support.6 Effective and competent leaders are empathetic, compassionate, and consider the impact of decisions on their direct reports.6 Competent leaders inspire and influence people to work toward a shared goal, gain voluntary commitment rather than compliance, and increase the recruitment and retention of quality employees.6

Forming the foundation

Collaborative and team-building skills are essential to nurse leaders of the future; however, creating positive and productive working relationships can be challenging.7 The healthcare team in 2020 is projected to be comprised of highly educated, multidisciplinary experts. Although this may appear to ease leadership challenges in team management and relationships, the exact opposite can occur. The greater the proportion of experts a team has, the more likely it is to disintegrate into a nonproductive competitive conflict or stalemate.8

Leaders can overcome conflict by demonstrating a commitment to collaboration, modelling highly collaborative behaviors themselves, and creating a sense of community by mentoring, resolving conflicts appropriately, and communicating clearly.8 Relationship conflicts are an inevitable outcome of the labor of leaders; however, successful navigation of these conflicts isn't inevitable and requires additional work.5 Conflicts must be recognized as opportunities to move forward, not as unresolvable obstacles.

Organizations must support leaders in the area of collaboration by providing resources that endorse collaboration and make the most of opportunities to examine and improve working relationships.5 For example, "constructive depolarizing" is one of the 10 new leadership skills for a world of volatility, uncertainty, complexity, and ambiguity.9 Constructive depolarizing is the "ability to calm tense situations where differences dominate and communication has broken down; and bring people from divergent cultures toward positive engagement."9 Constructive depolarizing is a positive skill needed in nursing leadership roles. Organizations that foster teamwork and support the forward motion of new ideas provide opportunities to revitalize the healthcare system.

Also of importance is "collegial and collaborative" relationships among professionals.10 Many academic and healthcare institutions are creating training programs for nurses, physicians, and pharmacists to support these important professional relationships. Interdisciplinary communication is critical to ensuring a safe patient environment. There's evidence that incorporating an interprofessional curriculum results in improved communication and support among nurses, physicians, and pharmacists.11

Several studies have shown that interpersonal relationships and interdisciplinary collaboration skills lead to better nursing leadership and can result in improved retention, satisfaction, and engagement of nurses.12-14 A review of 53 leadership-related studies concluded that leadership practices focused on relationships resulted in positive outcomes for both the nursing workforce and the work environment.15 Adherence to leadership competencies by nurse managers is positively associated with improved retention; nurses are more likely to stay at a job if they feel heard and understood by their managers.16

Reducing turnover and improving retention of nurses is essential to sustain quality healthcare organizations.16 Data collected on nursing turnover in Europe show that nurses most often leave the profession due to working conditions (including relationships) and family reasons.17 This mirrors what's seen in Canada and the United States.18,19 Providing nurses with good communication and collaboration skills may improve working conditions and increase work satisfaction among nursing staff members. It's clear from these studies that interpersonal relationships are important factors to consider when training nurse leaders.

Mixing up relationships

Healthcare growth is moving at a rapid rate and the need for nurses to be excellent change agents can't be overstated. Change is often guided or impacted by professional relationships. Relationship management and influencing behaviors are skills related to effective change implementation. These skills are identified as key components of the Nurse Manager Skills Inventory.20 Leaders today need to create an environment that accepts change and builds trust.21

Developing interpersonal relationships through collaborative interactions in the workplace should be the goal for nurse leaders because doing so is conducive to building a healthy work environment that ensures dedication and promotes positive work behavior.14 The AACN reports that these collaborations are among the most important elements in developing a healthy work environment.22 If nurse leaders apply effective leadership practices, it would promote better relationships with the nursing staff, as well as compel them to become more engaged in their work.

An essential component in developing interpersonal relationships is effective communication.23 Understanding the needs and wants of staff members and being able to recognize what motivates them is crucial for the nurse leader.24 When the employee perceives that his or her input is valued and has worth, this helps build trust and respect in his or her manager, which strengthens the work relationship.5 Positive relationships between the nurse leader and the nurse empower the nurse.25

As much as 90% of being a leader is about managing relationships.26 How can nurse leaders foster improved collaboration among their own staff members and among other healthcare professionals?

Adding the support

Experienced nurses are in a position to guide novice nurses as they begin their journey into the professional practice of nursing through mentorship and training. Across all levels of nursing, mentoring and/or preceptor programs exist and have shown to be effective, especially in the development of nursing leaders.27 Being a mentor is considered a primary aspect of leadership.28 The Robert Wood Johnson Foundation asserts that mentoring benefits the profession as a whole by helping to develop nurse leaders, retain nurses, and diversify the nursing workforce.29 Mentorships help to cultivate collegial relationships, encourage professional growth and development, and improve self-confidence and overall morale.30

Effective mentorship starts with evaluation of learning styles and forward planning; the mentor must recognize the mentee's learning style to understand individual learning needs.31 This enables the mentor to design appropriate interventions and guidance, which support an individual's progression. It also provides a structured framework to increase competency. This process must be continually reevaluated and feedback should be provided to the individual. It's equally important that mentorship programs are evaluated by the mentee so that the quality of the learning experience is enhanced to its full potential.31

Another approach to ensure that effective communication and relationship building are established among nurse leaders is through interdisciplinary collaboration. In the formal academic environment for healthcare providers, reforming the education requirements to include interdisciplinary teamwork and relationship building should be considered. Hospitals, with their structured hierarchy, which is often based on education and salary, inherently create an environment that may not support true collaboration.32

Organizational leaders should evaluate the collaborative capacity of the team. Often, when staff members are educated in hospitals, nurses are separated from physicians. Consider intentionally mixing the class/in-service with different disciplines. This will promote effective communication between the different disciplines, allowing for a new appreciation and respect for the strengths and individual perspectives of others, which could eventually lead to better environment and patient outcomes.33 Ensuring that all disciplines are represented on key organizational committees and teams, such as performance improvement teams or committees designed to change policy, can also support collaboration.

Other interventions that have been successful in developing interdisciplinary collaboration are daily interdisciplinary rounds and care plans that support interventions from different disciplines.34 These interventions simply require time for establishing the routine. Several academic institutions have piloted and implemented this interdisciplinary approach with positive results, but it's slow to become the standard.33

Stacking the blocks

Using emotional intelligence (EI) may support a healthy work environment and positive relationships.35 There are many definitions for EI, but all are based on understanding emotions, in self and others. EI is comprised of five different but very integrated components: self-awareness, self-regulation, motivation, empathy, and social skills, all of which are critical to relationship building.36 Nursing is often considered a stressful and demanding profession and operates with a high degree of emotion, both directly and indirectly, through caring for patients.37 It's imperative that nurse leaders be emotionally intelligent to support and manage nurses as they cope with these emotions and help them to regulate and express emotions in a way that positively meets the needs of the patient.38 EI is positively correlated with leadership effectiveness.39

Nurse leaders have opportunities to assert EI concepts in practice settings. A natural place to begin is during interview and orientation. During the interview process of a prospective candidate, in addition to focusing on his or her training and experience, implementing an EI assessment, such as the Bar-On Emotional Quotient Inventory or the Mayer-Salovey-Caruso Emotional Intelligence Test, can help a leader obtain a baseline EI measurement. After the hiring process is complete, comprehensive EI training can be completed during orientation.40 Through training and coaching, it's possible to grow one's EI quotient, which sets the scene to support positive relationships. Additionally, EI components and expectations can be added to job descriptions, or EI training updates can be part of annual competency reviews and performance evaluations.

Team-building interventions can also be utilized to promote communication and relationships among nurses. They can also result in greater problem solving, increased morale, and improved work coordination, which foster a culture of openness and lead to organizational effectiveness.41 Team-building interventions include highlighting group accomplishments through celebratory events; encouraging collegial networking through professional organizations, conferences, or education seminars; and arranging a staff retreat. Retreats provide the opportunity for nurses to step away from the workplace and build relationships with their fellow colleagues and leaders without the pressures of the clinical setting. Outcomes of retreats include professional development, increased cooperation among team members, staff satisfaction, opportunities for reward and recognition, and nurturing positive morale.41

Sealing in success

Nursing is a vital component to healthcare reform and all nurses must be equipped with leadership competencies to lead improvement and redesign healthcare in the United States. Clinical work environments largely impact patient and nursing outcomes, which is why it's extremely important that nurse leaders utilize leadership competencies to optimize and improve practice settings.

Communication and relationship management are key competencies noted in the literature that equip nurse leaders with the knowledge they need to improve clinical work environments by overcoming conflict, establishing collegial and collaborative relationships, enabling effective adaptation to change, and promoting a workplace that enhances job satisfaction and nurse retention. Communication and relationship building can be promoted at all levels of nursing through mentorship programs, interdisciplinary education, use of EI, and team-building interventions.

All nurses are leaders, in some capacity, despite their position because they have the ability to affect change in this rapidly evolving healthcare system.30 Experienced nurses, especially those with a Doctor of Nursing Practice (DNP) degree, are uniquely equipped to drive these changes through effective leadership.42 The leadership competencies set forth by the AONE serve as a foundation for DNP leaders.43 As healthcare continues to undergo changes, nursing leadership needs to be proactive and strive to create healthy work environments through effective communication and relationship building.

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