INTRODUCTION:Attitudes and clinical norms are shaped during medical training. Evidence from high-value care education suggests early exposure influences long-term practice patterns, making it an ideal target for curricula interventions. STARS (Students and Trainees Advocating for Resource Stewardship) is a learner-driven programme developed by Choosing Wisely Canada in 2015 and subsequently adopted in the USA. It exposes medical students to high-value care principles and activates them as change agents. We evaluated perceived sustained influence of the US STARS programme on attitudes, behaviours and professional development among medical students. METHODS:We conducted a mixed-methods programme evaluation of approximately 20% of participants from the first six U.S. cohorts (n=579; 2018-2023). Participants completed an anonymous retrospective pre-post survey assessing familiarity with healthcare value concepts and STARS' perceived influence. They also submitted annotated CVs reviewed for scholarly activities attributed to programme participation. Survey data were analysed using descriptive statistics. RESULTS:Ninety-four of 118 invited participants (80% response rate) completed both components. Participants reported that STARS influenced how they consider healthcare costs in clinical decision-making, discuss medical overuse with peers and appreciate the impact of costs on patients. Many attributed subsequent leadership activities and scholarly output to their participation, including quality improvement projects, peer-reviewed publications and locally implemented educational initiatives. CONCLUSION:This evaluation highlights the potential of learner-driven, longitudinal models such as STARS to foster durable engagement with high-value care education and catalyse professional development among medical trainees.
INTRODUCTION:Competency-based medical education in postgraduate medical education (PGME) prioritises developing holistic physicians, including leadership competence. The leadership competence encompasses self-management, working effectively in teams, considering organisational and societal demands and navigating complex situations. Although group reflection has proven valuable for leadership development in other professional fields, its role in PGME remains underexplored. This qualitative study investigated how small group reflection can support the development of leadership competence among PGME residents. METHOD:Using a constructivist grounded theory approach, a purposive sample of seven residents and seven counsellors from three Danish psychiatric hospitals were interviewed. Data analysis followed an iterative process of open, axial and selective coding, eventually constructing three themes. RESULTS:Three central themes related to leadership development were constructed: (1) community and safety, (2) perspective taking and (3) engagement. Residents valued a sense of community, which enabled open dialogues and a willingness to express vulnerability. This safe and supportive environment supported small group discussions. Exposure to diverse perspectives through group reflection broadened residents' understanding of leadership and helped them identify their strengths, areas for improvement and opportunities for action. Group reflection reinforced learning and facilitated further planning of leadership development. CONCLUSIONS:These findings show that group reflection is perceived as a valuable method for residents to develop leadership competence, supported by a sense of community and psychological safety. These insights can inform the design of new learning activities using group reflection as an educational tool, fostering leadership competences in PGME.
Purpose Hospital physician job satisfaction is critically low, leading to turnover and compromising patient care. This study examines how clinical directors’ clinical expertise influences subordinate physicians’ job satisfaction and intention to stay, exploring the mechanisms through which expert clinicians become effective managers. Methods We analysed multisource survey data from 184 clinical directors and 803 subordinate physicians in Danish public hospitals. Clinical expertise was measured through experience, education and peer recognition. We examined how expertise relates to human resource management (HRM) practices, perceived expertise and leader identity, and their effects on subordinates’ job satisfaction and retention intentions. Results Directors with higher clinical expertise implement better HRM practices, which significantly mediate the relationship between expertise and subordinate job satisfaction (β=0.03, p<0.05) and intention to stay (β=0.03, p<0.05). Clinical expertise correlates positively with leader identity (β=0.18, p<0.05), contradicting expectations that expert clinicians make reluctant managers. Perceived expertise showed weaker relationships than actual expertise. Practical implications The findings challenge assumptions that outstanding clinicians resist leadership roles, suggesting that clinical excellence and leader identity can coexist and are both important. Organisations should focus on developing HRM capabilities alongside leadership identity among expert clinicians to maximise subordinate satisfaction and retention.
Background Hospital performance management is frequently framed as a technical challenge centred on indicators, dashboards and analytics. Despite growing measurement infrastructures, many hospitals struggle to translate performance data into strategic leadership, effective governance and value-based improvement, suggesting that hospital performance management is a socio-organisational process shaped by leadership practices, institutional contexts and organisational dynamics. No review has systematically mapped how these socio-organisational dimensions are conceptualised across the hospital performance management literature. Methods Following Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews guidance, we conducted a scoping review across PubMed, Web of Science, Scopus and CINAHL. From 2612 records identified, 1749 unique titles and abstracts were screened. Of these, 50 met inclusion criteria; a purposive subsample of 40 studies presenting system-level or integrative frameworks underwent in-depth conceptual analysis. Findings were inductively organised into four thematic domains: tools & data; people & change; policy & governance and value-based healthcare. Results Hospital performance management emerges as a multidimensional, context-dependent and socially embedded phenomenon. In the included literature, performance measurement and performance management were frequently conflated, with implicit assumptions that indicator availability would translate into improvement. Technical solutions—including balanced scorecards, dashboards and analytics platforms—produced meaningful improvements only when embedded within supportive governance arrangements, engaged leadership and learning-oriented cultures. The balanced scorecard, while widely adopted, was selectively enacted according to dominant value orientations—functioning variably as a control, efficiency, learning or innovation tool depending on organisational context. Misalignment across technical tools, workforce dynamics, governance structures and value-based ambitions contributed to symbolic compliance and fragmented initiatives. A performance management architecture map and competing values framework interpretation are proposed to explain cross-study variation. Conclusions Hospital performance management failures stem less from inadequate indicators than from misalignment across measurement, governance, workforce and value-creation domains. Leaders should focus on aligning socio-organisational architectures, making value trade-offs explicit and using performance information to support organisational sense-making, coordination and learning rather than treating performance management as a compliance exercise.
INTRODUCTION:Climate change is increasingly recognised as both a public health emergency and a systemic stressor on healthcare systems. While many healthcare organisations have articulated ambitious climate and sustainability commitments, progress is frequently constrained by gaps in leadership capacity, governance and decision-making frameworks. Understanding what forms of leadership are required to move healthcare systems from climate ambition to operational readiness is a critical priority. APPROACH:This article draws on insights from two global technical meetings convened by the WHO's Alliance for Transformative Action on Climate Change and Health (ATACH), codesigned and cochaired by the Canadian Coalition for Green Healthcare and the International Hospital Federation's Geneva Sustainability Centre. The meetings brought together healthcare leaders from multiple levels within diverse resource settings. Leadership competencies were used as a guiding scaffold for the discussion. REFLECTIONS:Participants highlighted that climate-resilient healthcare requires system-oriented, value-informed and relational leadership exercised across frontline, organisational and community levels. Effective leadership was characterised by the ability to embed sustainability into routine decision-making, align climate action with quality, safety, equity and stewardship and create enabling structures beyond individual champions. These insights underscore that investing in leadership capacity is essential for delivering equitable, sustained and system-wide climate action in healthcare.
BACKGROUND:Newcomers to healthcare organisations often experience unspoken barriers to belonging, including cultural dissonance, microaggressions and systemic exclusion. As a visible minority and female leader, I frequently became a point of cultural reassurance for new staff seeking both guidance and recognition. REFLECTION:One interaction in particular, a question about where to find biryani spices locally, illustrated that newcomer staff were often seeking more than orientation to organisational processes. Many were also searching for connection, cultural familiarity and a sense of belonging within both the workplace and the broader community. This moment inspired the development of an open forum for internationally trained and newcomer staff to share experiences of exclusion, cultural adjustment and emotional labour. INSIGHT:This experience reinforced the importance of leadership grounded in empathy, authenticity and community-building. It also highlighted how representation can help create environments where staff feel comfortable sharing their experiences. Attention to team readiness, intentional facilitation and the use of facilitators without direct supervisory authority appeared to encourage participation and open discussion. IMPLICATIONS:Belonging cannot be mandated by policy alone; it emerges through relationship-based practices. Leaders must assess when teams are ready for equity-focused conversations, create accessible spaces for lived experience and resource psychological safety. As a result of this session, an employee resource group was launched, and broader discussions about equity have gained momentum.
Physician oaths are often treated as ceremonial relics or ethical ornaments of graduation. I have come to think they are something more demanding: early leadership texts. They declare what a profession publicly promises to protect. Yet modern healthcare is delivered not only through individual virtue but also through teams and systems with increasing reliance on checklists and technology. This raises a leadership question: what do physician oaths still teach us, and what do contemporary leaders need to add? This essay offers a reflective comparative reading of major oath and pledge traditions, together with later professionalism and governance literature. The aim is not to produce a systematic history of every oath variant but to read the tradition through a leadership-and-followership lens. The oath tradition has moved from sacred craft morality to public professionalism and then towards system and technology governance. Modern texts have become stronger on dignity, autonomy, equality and accountability. However, unnecessary blood or imaging tests, sleep disruption while in hospital, convenience-based restraint, fractured handovers within teams, documentation burden and electronic record bloat, defensive medicine and opaque use of artificial intelligence are endemic issues that require administrative, educational and clinical leadership attention. Newly graduated doctors usually enter practice first as followers, not formal leaders. Oath-taking should therefore be read not only as a promise of private virtue but also as an initiation into ethical followership, culture-building and responsible systems participation. A modern leadership reading of the oath should connect bedside morality with stewardship, trust, empathy, teamwork and accountable human oversight of technology.
Research-active clinical teams are linked with improved patient outcomes, enhanced service innovation and greater workforce development. Despite these benefits, embedding research within routine clinical roles in NHS mental health services remains challenging and requires coordinated leadership, cultural change and sustained organisational investment. This commentary reflects on the development of a clinical academic pathway within a United Kingdom (UK) mental health trust. Initiated through strategic commitment from the assistant director of research and catalysed by the proactive leadership of a clinical psychologist, the pathway evolved to include multiple professional groups and career stages. We describe the organisational enablers, leadership practices and barriers encountered during its development, including the importance of aligning research with service priorities, distributing leadership roles and protecting time for research activities. The reflections offer transferable lessons for NHS (National Health Service) leaders seeking to embed research within clinical practice and build sustainable clinical academic capacity in mental health services.
OBJECTIVES:To explore the motivations, barriers and systemic challenges experienced by senior doctors' engagement with compassionate and inclusive medical leadership (CIML) within Somerset NHS Foundation Trust, and to identify evidence-based strategies to support sustainable leadership development. DESIGN:A sequential mixed-methods study integrating quantitative survey data with qualitative thematic analysis and postsurvey facilitated group discussions. SETTING:Somerset NHS Foundation Trust, a large integrated healthcare organisation providing acute, community, mental health, learning disability and GP services across Somerset. PARTICIPANTS:Senior doctors including consultants and specialty associate specialist and specialist (SAS)-grade doctors. Participants included 156 survey respondents and 39 participants in postsurvey group discussions. OUTCOME MEASURES:Identifying leadership challenges, motivations, recruitment barriers and systemic facilitators of CIML engagement. Validation of survey findings through stakeholder discussions grounded in NHS leadership principles. RESULTS:Of the 692 eligible participants, 156 responded (22.5%) and 39 (5.64%) participated in the postsurvey group discussions. Key barriers to leadership engagement included time constraints (28%), lack of administrative support (20%), poor work-life balance (15%) and non-transparent recruitment practices (35%), echoing national concerns regarding clinician burnout and structural inequities. Qualitative themes reinforced these findings, highlighting cultural and systemic challenges, especially for women and ethnic minority doctors. Stakeholder discussions underscored the need for structured mentorship, protected time and inclusive leadership pathways. CONCLUSIONS:Systemic reforms, including mentorship programmes, transparent recruitment processes, leadership induction and protected time for leadership development, are essential to fostering sustainable and inclusive medical leadership. Engaging senior doctors in co-produced leadership strategies may help strengthen engagement and support more inclusive leadership cultures.
BACKGROUND:Allied Health Professional (AHP) services in England assess, diagnose, treat and rehabilitate patients across a wide range of health and care settings, supporting recovery and daily living. Persistent underinvestment in these services has led to delayed diagnoses, reduced access to rehabilitation and widening health inequalities, particularly in rural and coastal areas. METHODS:Interviews were conducted with 132 senior AHP leaders, with analysis informed by international evidence and national workforce literature. The study aimed to identify leadership concerns within services operating in rural and coastal areas of England. Qualitative coding was undertaken, supported by artificial intelligence-enabled analytical tools, to identify key themes. RESULTS:Six themes were generated from the data: (1) the importance of local leadership; (2) unlocking workforce pipeline development; (3) supportive leadership and organisational culture; (4) expanding access to rural workforce placements; (5) addressing lifestyle and professional viability and (6) strategic recruitment. Together, these themes inform potential solutions and more integrated approaches to improvement planning. DISCUSSION:The study identifies critical systemic barriers to recruitment, retention and leadership across the sector. Inconsistent leadership was associated with poorer service experience and outcomes in rural and coastal communities. These workforce challenges are structural rather than incidental, are potentially preventable and align with priorities set out in the NHS Long Term Workforce Plan. Recommendations for action are presented.
BACKGROUND:Despite the US population becoming increasingly diverse, gender and racial/ethnic disparities in academic paediatrics persist, limiting the provision of culturally effective care. Recent policy changes, including the US Supreme Court ruling against affirmative action, risk further exacerbating these disparities and impeding progress towards a more diverse healthcare workforce. OBJECTIVE:To examine trends in gender and race/ethnicity in academic paediatrics over 55 years, with a focus on identifying areas where representation remains limited. METHODS:A retrospective analysis of publicly available data from the Association of American Medical Colleges (AAMC) from 1966 to 2021 was conducted. Data on paediatric faculty members, categorised by gender, race and ethnicity, were analysed. Poisson regression models estimated annual growth rates and assessed trends in gender and racial/ethnic representation across academic ranks and department chairs. RESULTS:The paediatric workforce grew at an annual rate of 4.80% from 1966 to 2021. With a significantly higher growth rate compared with men (3.56%), women (6.43%) became the majority in the workforce by 2021. Racial/ethnic minoritised groups also showed significant growth. However, disparities persist in senior academic ranks and leadership positions, with men and White individuals still holding the majority of professor roles and department chair positions. CONCLUSIONS:Despite progress in gender and racial/ethnic representation in academic paediatrics, disparities remain, especially in senior ranks and leadership roles. These findings highlight the ongoing need for efforts to promote diversity, equity, and inclusion in paediatric academic medicine, especially in light of recent policy changes that may impede such initiatives.
BACKGROUND:The Oxford Health: Health Systems Development Programme was co-designed to strengthen multidisciplinary leadership capacity and address staff morale, engagement and autonomy. This study aimed to evaluate the mechanisms and outcomes of the programme. METHODS:Twenty-two participants completed the one year programme, which included six full-day workshops. We conducted a mixed-methods evaluation mapped to Kirkpatrick's framework. Pre-programme and post-programme self-assessments using an adapted Medical Leadership Competency Framework Questionnaire (MLCFQ) were analysed using Wilcoxon signed-rank tests with Bonferroni correction. Post-programme questionnaires, free-text responses and reflective essays (n=15) were analysed using reflexive thematic analysis. RESULTS:Workshops were highly rated for relevance and experience. There were statistically significant improvements in two MLCFQ domains: managing services and setting direction (p=0.02). Psychological safety, legitimised vulnerability and structured reflection were identified in qualitative data as central mechanisms for change. Participants reported increased leadership self-efficacy, systems-thinking and confidence in speaking up. Behavioural transfer included deliberate cultivation of psychological safety and broader ranges of approaches to leadership. Reported organisational impacts included increased staff voice, team cohesion and early service-level improvements. CONCLUSIONS:This evaluation demonstrates credible evidence of behavioural transfer and early organisational influence. Strengthened longitudinal evaluation and predefined service-level metrics are required to assess sustainability and objective impact.
BACKGROUND:Climate change is one of the greatest threats to human health. The UK health and care system is responsible for 4%-5% of the country's carbon footprint. Following an ambitious commitment to 'Delivering a Net Zero NHS', there is an ongoing urgent drive to advocate for proactive sustainability measures across the workforce healthcare practice areas. As the third largest workforce within the NHS, allied health professionals (AHPs) are crucial players in this net zero commitment. Implementing suitable carbon reduction strategies requires leadership and more clarity on the practical steps that AHPs can take specific to their unique skill set. OBJECTIVE:This study aimed to develop a professional consensus on the actionable carbon reduction priorities across a sample of AHP professions. SETTING:AHPs working in diverse areas of practice. PARTICIPANTS:n=101 participants from n=10 AHP professional disciplines. METHODS:Using an adapted nominal group technique, 10 workshops were run with AHP professional disciplines to discuss practice-related carbon reduction priorities. Within workshops, ideas were discussed, scored and ranked to produce a final consensus on the top (5 or 10) priorities for carbon reduction for each profession. RESULTS:Via thematic analysis, five cross-cutting themes emerged: (a) resource use; (b) preventative healthcare; (c) digital transformation; (d) professional development/training and (e) service efficiency/re-design. Findings align closely with those highlighted in the 'AHPs Deliver' strategic vision to prioritise environmental sustainability across practice areas. They also concur with the urgent call for stronger leadership within healthcare to embed sustainability and planetary health into 'business as usual' function. CONCLUSIONS:Despite some inherent limitations (eg, purposive sampling, which might have presented bias) this study provides a solid foundation on which to base future action to reduce carbon emissions within the UK healthcare context. Recommendations are made for AHP practice, advocacy and culture change, and for bold (collaborative) leadership to spearhead and direct transformational change towards greener healthcare across the AHP community.
BACKGROUND:With the rapid implementation of artificial intelligence (AI) in radiographer workflows, leadership roles are necessary for its safe and effective integration into practice. Due to their dual professional identity (encompassing patient-centred care skills and technical skills) radiographers emerge as natural AI leaders within the medical imaging and radiotherapy ecosystems. AIM:To examine how UK radiographers perceive their readiness, confidence and potential roles in AI leadership, and to identify the barriers and enablers for their engagement within the AI-ecosystem. METHODS:A UK-wide, cross-sectional, online survey of radiographers and students (n=273) combined demographic questions, AI knowledge and experience questions, Likert-type assessments of preparedness and free text responses. Quantitative data were analysed using descriptive statistics and Mann-Whitney U tests; qualitative data underwent thematic content analysis. RESULTS:Most respondents reported limited AI literacy and minimal hands-on experience, citing insufficient education, protected time and managerial support as key barriers to leadership readiness. Confidence varied: women and those with little AI exposure, expressed statistically significant lower confidence to lead in AI-enabled environments. Respondents felt more comfortable taking on leadership responsibilities once AI systems were already in place than leading their implementation. Qualitative findings indicated that in this predominantly frontline sample, radiographers described AI leadership mainly as operational, practice-based work. Motivations for leadership focused on improving workflows, supporting colleagues and ensuring safe practice. DISCUSSION/CONCLUSIONS:Radiographers recognise the relevance of AI leadership but understand it as practice-proximal, operational-focused responsibilities, due to limited AI exposure, uneven confidence and the absence of defined leadership pathways in national policy. Role ambiguity and limited experiential learning constrain radiographers' ability to envision strategic or organisation-wide AI leadership. Profession-specific education, structured experiential opportunities and organisational support are essential for enabling radiographers to participate equitably and effectively in AI-enabled service transformation.
BACKGROUND:Clinician well-being has been linked to leadership assessment, yet the relative impact of satisfaction with direct supervisors versus senior leadership remains underexplored. Understanding these relationships can inform leadership development and organisational strategies to mitigate burnout. METHODS:We administered a well-being survey to all frontline clinicians at a large US health system in Spring 2023 (response rate 24.5%). Independent variables included satisfaction with immediate supervisors and senior leadership, operationalised from five-point Likert items. Burnout was assessed using the Professional Fulfillment Index. Linear probability models estimated the association of leadership satisfaction with burnout, adjusting for clinician type and gender. Stratified analyses examined differences across nurses, advanced practice providers, physician trainees and attending physicians. RESULTS:Among 3707 respondents, 36.3% met criteria for burnout. Satisfaction with senior leadership was associated with an 83.7% lower probability of burnout (B=-0.304, p<0.001), compared with 32.2% for direct supervisors (B=-0.117, p<0.001). Findings were consistent across clinician groups, with senior leadership satisfaction demonstrating the largest effect, particularly among nurses. CONCLUSIONS:Satisfaction with senior leadership exerts a stronger influence on burnout than satisfaction with immediate supervisors. Interventions that support senior leadership development may yield significant benefits for frontline healthcare worker well-being and retention.
BACKGROUND:Healthcare systems are increasingly characterised by complexity, uncertainty and the need for adaptive leadership. This study reports on a cooperative inquiry conducted with senior medical professionals in an Irish public rehabilitation hospital during the COVID-19 pandemic and a concurrent hospital relocation. The inquiry aimed to explore how reflective practice and collaborative learning could support leadership, well-being and organisational change in this dynamic context. METHODS:The cooperative inquiry involved six iterative cycles with 4-12 participants per session over an 18-month period. Participants engaged in structured reflection, collective dialogue and co-designed actions. Qualitative data were drawn from meeting notes, reflective journals and outputs such as action plans and feedback loops. Analysis focused on emergent themes across the cycles and evaluation of enacted changes. The process was informed by complexity leadership theory and action research methodology. RESULTS:Key themes that were generated across cycles included trust, connection, psychological safety, professional isolation and adaptive leadership. Actions included establishing new communication platforms (eg, WhatsApp groups), embedding reflective practice, engaging with executive decision-making structures and initiating governance innovations. Participants reported increased capacity for navigating complexity, improved collegial support and expanded organisational influence. Reflective practice and relational leadership emerged as core mechanisms of change. CONCLUSION:The inquiry demonstrated how cooperative, reflective processes can support the emergence of adaptive and relational leadership and enable organisational learning in complex healthcare settings. Even under conditions of crisis and constraint, participants cultivated a learning community that contributed to meaningful professional and systemic development. The study provides an empirical account of the mechanisms through which cooperative, reflective processes support the emergence of adaptive and relational leadership in complex healthcare settings.
