Leadership curricula and assessment in Australian and New Zealand medical schools.

BACKGROUND: The Australian Medical Council, which accredits Australian medical schools, recommends medical leadership graduate outcomes be taught, assessed and accredited. In Australia and New Zealand (Australasia) there is a significant research gap and no national consensus on how to educate, assess, and evaluate leadership skills in medical professional entry degree/programs. This study aims to investigate the current curricula, assessment and evaluation of medical leadership in Australasian medical degrees, with particular focus on the roles and responsibilities of medical leadership teachers, frameworks used and competencies taught, methods of delivery, and barriers to teaching leadership. METHODS: A self-administered cross-sectional survey was distributed to senior academics and/or heads or Deans of Australasian medical schools. Data for closed questions and ordinal data of each Likert scale response were described via frequency analysis. Content analysis was undertaken on free text responses and coded manually. RESULTS: Sixteen of the 22 eligible (73%) medical degrees completed the full survey and 100% of those indicate that leadership is taught in their degree. In most degrees (11, 69%) leadership is taught as a common theme integrated throughout the curricula across several subjects. There is a variety of leadership competencies taught, with strengths being communication (100%), evidence based practice (100%), critical reflective practice (94%), self-management (81%), ethical decision making (81%), critical thinking and decision making (81%). Major gaps in teaching were financial management (20%), strategic planning (31%) and workforce planning (31%). The teaching methods used to deliver medical leadership within the curricula are diverse, with many degrees providing opportunities for leadership teaching for students outside the curricula. Most degrees (10, 59%) assess the leadership education, with one-third (6, 35%) evaluating it. CONCLUSIONS: Medical leadership competencies are taught in most degrees, but key leadership competencies are not being taught and there appears to be no continuous quality improvement process for leadership education. There is much more we can do as medical educators, academics and leaders to shape professional development of academics to teach medical leadership, and to agree on required leadership skills set for our students so they can proactively shape the future of the health care system.

Medical Students' perceptions and attitudes toward Medical Leadership and Management.

OBJECTIVES: To find out medical students' perceptions and attitudes toward medical leadership and management (MLM). METHODS: A total of 336 medical students from the 2nd to 6th academic years from King Abdulaziz University (KAU), Jeddah, Kingdom of Saudi Arabia (KSA), were included in this cross-sectional study. This study was conducted in January-February 2020. The students were asked about their perceptions, attitudes, and interests in the leadership of medical care and clinicians. A four-part questionnaire was used for collecting data. SPSS-21 was used for analysis. RESULTS: The participants included 172 (51.2%) males and 164 (48.8%) females. In total, 105 (31.3%) participants agreed that they had been very well educated about their perception, behavior, and interest in the field of medical leadership and clinic management, and 175 (52.1%) students agreed that clinicians should influence management decisions in a healthcare setting. Overall, 167 (49.7%) students agreed that management/leadership skills are important for clinicians. In total, 145 students (43.2%) desired to have more leadership training in medical school, and 129 (38.4%) students agreed to seek additional leadership/management training in their postgraduate research studies. When asked about their self-perception of good leadership skills, the students indicated that good leadership skills included integrity (47.9%), conflict resolution (46.7%), organization (44.4%), confidence (41.9%), communication (40.5%), self-reflection (40.2%), time management (33.6%), the ability to motivate others (36.9%), and the ability to keep calm under stress (33.3%). CONCLUSION: Many students were well aware of the MLM concepts. However, students agreed that management/leadership skills are important for clinicians, and there should be more leadership training in medical schools.

From context to contexting: professional identity un/doing in a medical leadership development programme.

Physicians are known for safeguarding their professional identities against organisational influences. However, this study shows how a medical leadership programme enables the reconstruction of professional identities that work with rather than against organisational and institutional contexts to improve quality and efficiency of care. Based on an ethnographic study, the results illustrate how physicians initially construct conflicting leadership narratives - heroic (pioneer), clinical (patient's guardian) and collaborative (linking pin) leader - in reaction to changing organisational and clinical demands. Each narrative contains a particular relational-agentic view of physicians regarding the contexts of hospitals: respectively as individually shapeable; disconnected or collectively adjustable. Interactions between teachers, participants, group discussions and in-hospital experiences led to the gradual deconstruction of the heroic -and clinical leader narrative. Collaborative leadership emerged as the desirable new professional identity. We contribute to the professional identity literature by illustrating how physicians make a gradual transition from viewing organisational and institutional contexts as pre-given to contexting, that is, continuously adjusting the context with others. When engaged in contexting, physicians increasingly consider managers and directors as necessary partners and colleague-physicians who do not wish to change as the new 'anti-identity'.

Development of a national medical leadership competency framework: the Dutch approach.

BACKGROUND: The concept of medical leadership (ML) can enhance physicians' inclusion in efforts for higher quality healthcare. Despite ML's spiking popularity, only a few countries have built a national taxonomy to facilitate ML competency education and training. In this paper we discuss the development of the Dutch ML competency framework with two objectives: to account for the framework's making and to complement to known approaches of developing such frameworks. METHODS: We designed a research approach and analyzed data from multiple sources based on Grounded Theory. Facilitated by the Royal Dutch Medical Association, a group of 14 volunteer researchers met over a period of 2.5 years to perform: 1) literature review; 2) individual interviews; 3) focus groups; 4) online surveys; 5) international framework comparison; and 6) comprehensive data synthesis. RESULTS: The developmental processes that led to the framework provided a taxonomic depiction of ML in Dutch perspective. It can be seen as a canonical 'knowledge artefact' created by a community of practice and comprises of a contemporary definition of ML and 12 domains, each entailing four distinct ML competencies. CONCLUSIONS: This paper demonstrates how a new language for ML can be created in a healthcare system. The success of our approach to capture insights, expectations and demands relating leadership by Dutch physicians depended on close involvement of the Dutch national medical associations and a nationally active community of practice; voluntary work of diverse researchers and medical practitioners and an appropriate research design that used multiple methods and strategies to circumvent reverberation of established opinions and conventionalisms. IMPLICATIONS: The experiences reported here may provide inspiration and guidance for those anticipating similar work in other countries to develop a tailored approach to create a ML framework.

Medical leadership competencies: A comparative study of physicians in public and private sector hospitals in India.

PURPOSE: Indian health care system comprising of public and private sectors needs enhancement of medical leadership capacity to face the growing challenges. Hence, this study was designed to evaluate medical leadership competencies of public and private sector doctors. FINDINGS: A survey questionnaire was developed to assess "self-assessed proficiency levels" as well as "perceived importance of competency levels," to which 532 doctors responded-290 (54.5%) from private sector and 242 (45.5%) from public sector hospitals. Statistically significant "leadership competency gap" was observed for all 30 leadership competencies in both sectors, more so in public sector. The 10 most deficient competencies were mainly in the NHS-MLCF domains of "working with others," "managing services," and "setting direction." The most low-rated competency among public sector doctors was "knowledge of HR, procurement, financial, and contract management" while "ability to influence key decision makers who determine future government policies" was most deficient among private sector physicians. Further, deficiencies related to "time and stress management" and "conducting need analysis, identifying and prioritizing requirements" were confined to public and private sector doctors, respectively. CONCLUSIONS: This study, first from India, highlights a critical need for medical leadership development programs in both sectors for enhancement of medical leadership capacity in the country.

Medical leadership and management in the United Kingdom.

OBJECTIVE: This article aims to outline the historical development of medical leadership in the United Kingdom (UK), present recent advances, and discuss professional development and future prospects. CONCLUSIONS: With increasing involvement of medical professionals in top managerial roles in the UK over the last 30 years, leadership development initiatives have been growing steadily and there is increasing recognition of the need for leadership and management skills for doctors. Such skills can help to greatly improve patient care as well as enhance organisational effectiveness and productivity. The central involvement of professional bodies such as the UK Faculty of Medical Leadership and Management, and the establishment of medical fellowship schemes, have provided a solid foundation for a new generation of aspiring medical leaders but there is still a long way to go to achieve a higher degree of professionalism for clinical leadership in the UK. The evidence base is weak such that integrated efforts by clinicians and management academics have much to offer in achieving the vision of socially responsible, clinically relevant and research informed medical leadership training.

The impact of an integrated medical leadership programme.

PURPOSE: The purpose of this paper is to determine the impact of an integrated Medical Leadership Programme (MLP) on a cohort of participating specialty doctors and the NHS services with which they were engaged. DESIGN/METHODOLOGY/APPROACH: This was a qualitative study designed to obtain rich textual data on a novel training intervention. Semi-structured interviews were conducted with participating MLP trainees at fixed points throughout the programme in order to capture their experiences. Resulting data were triangulated with data from extant documentation, including trainees' progress reports and summaries of achievements. Recurring discourses and themes were identified using a framework thematic analysis. FINDINGS: Evidence of the positive impact upon trainees and NHS services was identified, along with challenges. Evidence of impact across all the domains within the national Medical Leadership Competency Framework was also identified, including demonstrating personal qualities, working with others, managing services, improving services and setting direction. RESEARCH LIMITATIONS/IMPLICATIONS: Data were drawn from interviews with a small population of trainees undertaking a pilot MLP in a single deanery, so there are inevitable limitations for generalisability in the quantitative sense. Whilst the pilot trainees were a self-selected group, it was a group of mixed origin and ability. PRACTICAL IMPLICATIONS: The study has provided valuable lessons for the design of future leadership programmes aimed at doctors in training. ORIGINALITY/VALUE: Identifying the effectiveness of an innovative model of delivery with regard to the Medical Leadership Curriculum may assist with medical staff engagement and support health service improvements to benefit patient care.

Thematic analysis of tools for health innovators and organisation leaders to develop digital health solutions fit for climate change.

OBJECTIVES: While ethicists have largely underscored the risks raised by digital health solutions that operate with or without artificial intelligence (AI), limited research has addressed the need to also mitigate their environmental footprint and equip health innovators as well as organisation leaders to meet responsibility requirements that go beyond clinical safety, efficacy and ethics. Drawing on the Responsible Innovation in Health framework, this qualitative study asks: (1) what are the practice-oriented tools available for innovators to develop environmentally sustainable digital solutions and (2) how are organisation leaders supposed to support them in this endeavour? METHODS: Focusing on a subset of 34 tools identified through a comprehensive scoping review (health sciences, computer sciences, engineering and social sciences), our qualitative thematic analysis identifies and illustrates how two responsibility principles-environmental sustainability and organisational responsibility-are meant to be put in practice. RESULTS: Guidance to make environmentally sustainable digital solutions is found in 11 tools whereas organisational responsibility is described in 33 tools. The former tools focus on reducing energy and materials consumption as well as pollution and waste production. The latter tools highlight executive roles for data risk management, data ethics and AI ethics. Only four tools translate environmental sustainability issues into tangible organisational responsibilities. CONCLUSIONS: Recognising that key design and development decisions in the digital health industry are largely shaped by market considerations, this study indicates that significant work lies ahead for medical and organisation leaders to support the development of solutions fit for climate change.

What can healthcare organisations do to improve medical engagement? A systematic review.

BACKGROUND: Medical engagement is linked to improved outcomes for staff and patients including a reduction in staff turnover. There are significant problems with recruitment and retention of doctors globally, it is, therefore, important to try to increase medical engagement within healthcare organisations. This systematic review aimed to review evidence from 2018 to 2023 from peer-reviewed journals on interventions to improve medical engagement and from this generate practical recommendations for healthcare organisations. METHOD: A search strategy was developed and used across six databases alongside citation searching. Articles were screened to check whether they met the study criteria and were then critically appraised. The interventions were extracted and a thematic analysis, using an inductive approach, was undertaken. RESULTS: 15 articles were found to have met the criteria, however, the studies were generally found to be of low-quality research evidence. The interventions from the articles were grouped into nine themes covering topics such as 'Improvements to working conditions', 'Increasing support to doctors' and 'Rewards/incentives/recognition'. CONCLUSION: The review generated a wide range of interventions which could be used to improve medical engagement, however, critical appraisal revealed that they were of low-quality evidence, so their effectiveness should be interpreted with some caution. The majority of the interventions were transferable to healthcare settings, with some limitations depending on the country. Several HR models were described as options for implementing these interventions within healthcare organisations. Further high-quality research is needed in this area.

How the 'Health Leader-as-Coach' benefits health leaders, their teams, peers, organisation and the system.

One of the main ways in which health leaders at all levels can be developed on a daily basis has been neglected by clinical leadership research, and by the research community generally, relating to the leader consciously using evidence-based coaching skills to positively impact their direct reports, team members, peers, organisations and the wider system in the context of their vocational role, as 'Leader-as-Coach'.This paper summarises the research on the role of 'Leader-as-Coach', and translates the learning from this into the practice of clinical leadership development.Line managers are increasingly expected to use a coaching approach and are in an ideal position to do so. While there are many similarities with professional external coaching, the behaviours of the 'Leader-as-Coach' are also not identical and multiple ethical issues can arise.There is no consistent academic definition to describe the behaviours of coaching in the context of a leader's vocational role, nor yet specific competencies for training or supervision purposes.The outcomes are summarised from the known literature in this field. Individual and system challenges are then discussed and conclusions are drawn about what this research means in practice for clinical leaders and their systems.

History and its relevance to contemporary and future leadership.

BACKGROUND/AIM: This paper argues that an inquisitiveness into the history of medicine and healthcare organisation is an important characteristic of a leader seeking to understand why facts are as they are, before embarking on leading change. I had the privilege of 34 years of service in the UK Defence Medical Services, culminating in the most senior role of Surgeon General. I, and many of my military medical colleagues, are members of the Faculty of Medical Leadership and Management. Through this, I hope that we have been able to add an interesting dimension to the practice of medical leadership in UK health organisations. METHODS: This paper is a reflection on my personal experience suggesting that studying the history of military medicine can provide insights into the collective knowledge of previous generations, the process of organisational development during war, and the clinical and system innovations needed for the next war. RESULTS: This paper summarises my personal experience of the relevance of the history of military medicine in clinical practice and policy development within the UK Defence Medical Services. It has five sections starting with history as a trajectory of knowledge, and how this links to my personal career. I then show how history informed my leadership influence on policy and practice in four topics: the prevention of heat illness, the organisation of medical services, partnerships in military medicine, and organisational learning. The paper is framed around my personal experience over a career that spanned clinical practice, policy development, leadership on military operations, and finally senior strategic roles. CONCLUSION: While I have placed my argument in the context of military medical leadership, I suggest that understanding history is just as important in civilian medical leadership.

What makes for a 'Top Doc'? An analysis of UK press portrayals of so-called top doctors.

OBJECTIVE: To determine the characteristics of medical practitioners designated 'top doctor' or 'Top Doc' in the UK press. DESIGN: Observational study of news stories related to the term top doctor (or Top Doc) with analysis using data from publicly available databases. SETTING: News reports in the UK press accessed via a database from national newspapers from 1 January 2019 to 31 December 2019, prior to the COVID-19 pandemic. Stories relating to disciplinary/criminal matters were analysed separately. MAIN OUTCOME MEASURES: Results were cross-referenced with the General Medical Council register of medical practitioners for gender, year of qualification, whether on the general practitioner (GP) or the specialist register, and if on the specialist register, which specialty. RESULTS: There was a gender divide, with 80% of so-called top doctors being male. National top doctors had been qualified for a median time of 31 years. Top doctors are widely spread among specialties; 21% of top doctors were on the GP register. Officers of the British Medical Association and the various Royal Colleges are also well represented. 'Top doctors' facing disciplinary proceedings are more overwhelmingly male, working in hospital specialties and less obviously eminent in their field. CONCLUSION: There is no clear definition of a 'top doctor', nor are there objective leadership criteria for journalists to use when applying this label. Establishing a definition of 'top doctor', for instance, via the UK Faculty for Medical Leadership and Management, which offers postnominals and accreditation for high-achieving medical professionals, may reduce subjectivity.

Five hats of effective leaders: teacher, mentor, coach, supervisor and sponsor.

BACKGROUND/AIM: Teaching, mentoring, coaching, supervising and sponsoring are often conflated in the literature. In this reflection, we clarify the distinctions, the benefits and the drawbacks of each approach. We describe a conceptual model for effective leadership conversations where leaders dynamically and deliberately 'wear the hats' of teacher, mentor, coach, supervisor and/or sponsor during a single conversation. METHODS: As three experienced physician leaders and educators, we collaborated to write this reflection on how leaders may deliberately alter their approach during dynamic conversations with colleagues. Each of us brings our own perspective and lens. RESULTS: We articulate how each of the 'five hats' of teacher, mentor, coach, supervisor and sponsor may help or hinder effectiveness. We discuss how a leader may 'switch' hats to engage, support and develop colleagues across an ever-expanding range of contexts and settings. We demonstrate how a leader might 'wear the five hats' during conversations about career advancement and burn-out. CONCLUSION: Effective leaders teach, mentor, coach, supervise and sponsor during conversations with colleagues. These leaders employ a deliberate, dynamic and adaptive approach to better serve the needs of their colleagues at the moment.

Evidence behind the exhortation? A rapid review of servant leadership's influence and claims in healthcare over the last decade.

Servant leadership is an other-oriented approach to leadership with multiple positive outcomes. However, its influence in the context of medicine, particularly on healthcare leaders, is less clear. We conducted a rapid review to examine the impact of servant leadership in healthcare over the last decade. We included a total of 28 articles, 26 of which described beneficial organisational, relational and personal outcomes of servant leadership. However, most of these were either conceptual or opinion-based articles. Moreover, most quantitative studies were cross-sectional, precluding causal inferences. Our review demonstrates that the purported positive association between servant leadership and healthcare outcomes lacks a strong evidence base. We conclude by calling for more rigorous empirical research to examine the effects and potential challenges of implementing servant leadership in healthcare contexts.

Building towards organisational resilience and complexity leadership: a case study of impacts and changes in a Dutch blood establishment during COVID-19.

OBJECTIVES: This study examined how one large blood-related establishment coped and adapted during the first 1.5 years of the pandemic by evaluating the impacts and changes on its resources, communication, collaborations, and monitoring and feedback. Furthermore, we explored whether elements of complexity leadership emerged during this time. DESIGN: Duchek's organisational resilience framework was primarily used. We followed a three-step sequential approach: (1) a document analysis of over 150 intranet, internet and internal reports; (2) 31 semistructured interviews with employees and (3) four feedback sessions. SETTING: Sanquin is known as the Dutch national blood bank and a large multidivisional expertise organisation in the Netherlands. RESULTS: Sanquin coped well. Respondents accepted the crisis and catalysed many collaborations to implement solutions, which were communicated to the public. There were many positive aspects related to internal collaborations, yet challenges remained related to its historical siloed structure and culture. Sanquin adapted partially. Many respondents experienced the organisation becoming more connected and flexible during the pandemic. However, Sanquin was not permanently changed due to significant leadership changes and organisational restructuring occurring simultaneously. Respondents reflected on lessons learnt, including the need for continual collaboration and improvements in Sanquin's culture. An important driver in the successful coping was management's enabling attitude and the adaptations occurring within and through the collaborative groups. CONCLUSIONS: Sanquin improved its organisational resilience by exhibiting elements of adaptive spaces, enabling leadership and (temporary) emergence from complexity leadership. This illuminates how the organisation could continue benefiting from complexity leadership for non-crises and for future uncertainties.

Cultivating the next generation of healthcare leaders: reflections from an established healthcare leader.

BACKGROUND: Dr Andrea Doria is Professor and Vice-Chair of Radiology (Clinical Practice Improvement) at the University of Toronto, Research Director, Senior Scientist and Imaging Lead of Personalised Child Health, The Hospital for Sick Children (SickKids), Toronto, Canada. Over the past few decades, Dr Doria has established a track record of healthcare leadership. Based on Dr Doria's extensive leadership experience, she believes it is essential for established healthcare leaders to be involved in cultivating emerging healthcare leaders. METHODS: An interview was conducted with Dr Doria to learn about key lessons she believes are essential for healthcare leaders to help develop the next generation. Dr Doria reflected on her leadership style and experiences, sharing what has worked to improve the effectiveness of her teams. RESULTS: Key messages were reflected upon, including practical ways for senior leaders to support the next generation; leadership insights gained from the pandemic; the importance of building diversity in teams and nurturing leaders from underrepresented minorities; challenges to be aware of for the future of healthcare leadership; finding inspiration from team members and essential traits for healthcare leaders. CONCLUSION: Through cultivating the next generation of healthcare leaders, established leaders can be involved in establishing a brighter future for healthcare. This article describes reflections and practical takeaways that can help established leaders support emerging leaders and build their leadership skills.

Evaluation of the first 5 years of the Next Generation GP leadership programme: balancing autonomy and accountability.

BACKGROUND: In 2017, a group of trainee general practitioners (GPs) came together to design and deliver a six-session leadership development programme for their peer trainee and early career GPs: the Next Generation GP programme. Over 2500 GPs took part in Next Generation GP between 2017 and 2022. AIM: To evaluate the origins and development of the Next Generation GP programme, its early impact on individuals and general practice, and what it reveals about GPs' needs for career and leadership development at a time of major workforce and demand pressures. METHODS: A rapid review of evidence on general practice workforce and career trends informed the design of qualitative research interviews (n=28) with a purposive sample of programme participants, primary care leaders and educational experts. This was supplemented by analysis of secondary data from participant evaluations of programme workshops. RESULTS: Many programme participants reported: improved competence in leadership skills, increased understanding of the health system, having new support networks and more energy for their GP role. Respondents pointed out the strengths of the programme, also highlighting ways in which it could be adapted to enable a transition to a more sustainable position within broader clinical and leadership career development. CONCLUSIONS: Next Generation GP has to date largely fulfilled its programme objectives. It now needs more tangible, longer-term objectives against which to assess outcomes. This evaluation has contributed to evidence about primary care leadership needing more policy attention, for the balance of autonomy and accountability within GP leadership needs careful and sustained support.

Role of emotions in change and change management in an emergency department: a qualitative study.

BACKGROUND: Changes in emergency departments are frequently implemented to improve efficiency and reduce costs. However, staff acceptance and adoption are crucial for the intended success of changes. OBJECTIVES: This study explored staff perceptions of factors influencing the implementation of changes and any common themes linking changes and factors influencing changes in an emergency department at a university teaching hospital in the UK. METHODS: We used constructivist grounded theory methodology to perform a secondary analysis of 41 interview transcripts of physicians, nurses, support workers and managers involved in paediatric emergency care. RESULTS: Participants identified leadership, communication and education as factors impacting change management. They described many emotions associated with changes and with communication, leadership and education or the lack of any of them during changes. Both positive and negative emotions sometimes coexisted at individual, team or organisational levels. Negative emotions were due to real-life challenges and concern over compromised patient care. Professional values dictated the actions or inactions that transpired either because of these emotions or despite these emotions in health professionals. CONCLUSIONS: Emotions to change should be acknowledged and addressed by credible leadership clear communication and education to improve the change process, its success and ultimately, patient care.

Medical education needs a new model for global leadership.

BACKGROUND: Like other fields in medicine, medical education relies on collaboration and cooperation between countries and regions of the world, although no single institution or position unifies the global medical education community in the way that the WHO does in public health, for example. Recent research in medical education has drawn attention to many injustices that exist in the field, where power and influence is held in relatively few Global North countries, although most practice happens in Global South countries. METHODS: In this article, we examine three positions that hold global prominence in medical education, including the presidents of the World Federation for Medical Education and the Association for Medical Education in Europe, and winners of the Karolinska Institutet Prize for Research in Medical Education. FINDINGS: We highlight that these positions have problematic histories and have perpetuated the current power disparities in the field. We argue that an alternative model for global leadership is required that should be determined democratically by those involved in medical education all around the world. Such a model should prioritise diversity and inclusivity, empowering leaders from countries who have previously been peripheral to the decision-making platforms in the field. CONCLUSION: Given the shortcomings of existing leadership positions and organisations, we suggest that a new institution is required to realise this new vision, and that the principles that govern it should be determined through debate and democracy, with a focus on inviting those voices that have not previously been heard in global medical education circles.

Participation in staff engagement campaigns at large healthcare organisations: a focus group study.

INTRODUCTION: Healthcare organisations work better with an engaged workforce, and staff-engagement campaigns offer a method to build this engagement. Leeds Teaching Hospitals NHS Trust (LTHT), one of the UK's largest Trusts, provides an example of where an organisation-wide engagement intervention has been used in a healthcare setting. This study aimed to understand why staff participate, or do not participate, in staff-engagement campaigns, supporting healthcare leaders to increase participation in future campaigns. METHODS: Scenario-based focus groups were carried out across five different organisational units within LTHT. The data from these were transcribed, coded and analysed using reflective thematic analysis. RESULTS: Participation in staff-engagement campaigns is dependent on campaign awareness, staff perceptions of the campaign and the practicalities associated with participation. Perceptions of the campaign are further subdivided into the campaign's perceived effectiveness, purpose and relevance. CONCLUSIONS: Staff engagement was a powerful driver of participation, which presents a conundrum: how do you encourage participation in staff-engagement campaigns, if engagement is a prerequisite for participation? The answer lies in taking advantage of organisational belongingness and visible leadership, supported by communications that take control of the narrative around the campaign. Behavioural science models may guide leaders across the organisation in mapping where these approaches can have the greatest impact within their existing spheres of influence. Further, considering inequalities around participation across different groups may help target action to the areas of greatest need. Accordingly, the research provides pragmatic guidance for leaders in thinking about how to use staff-engagement campaigns more effectively.