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This study examines the direct influence of participatory leadership (PL) and supportive organisational culture (SOC) on employee job satisfaction (JC). Additionally, the research delves into the mediating role of work-life balance in the relationship between PL, SOC, and job satisfaction. Data was collected using 450 questionnaires through random sampling from hotels managing food security in Saudi Arabia. These findings indicate a direct correlation between participatory leadership, supportive organisational culture, and job satisfaction. Furthermore, work-life balance was found to mediate the relationship between PL, SOC, and job satisfaction. Given the importance of a supportive organisational culture for robustness, this study suggests that hotels, particularly those managing food security in Saudi Arabia, should prioritise fostering a supportive culture. They should also encourage democratic leadership and formulate strategies to help employees achieve work-life balance (WLB), leading to enhanced job satisfaction.

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Incivility is a major concern in healthcare, and it is vital that uncivil behaviour is recognised and addressed. Manifestations of incivility are wide ranging and can take the form of microaggressions, which are difficult to pinpoint but have significant repercussions. Research has demonstrated the negative effects of incivility on staff and patients. Uncivil acts and behaviour can create conflict, reduce performance, affect morale, decrease retention and jeopardise patient safety. The role of nurse managers in reducing incivility and promoting civility includes providing leadership, fostering psychological safety, creating a shared understanding of civil behaviour and managing uncivil behaviour as soon as it occurs. The input of employers is crucial to promote a compassionate and inclusive organisational culture and to support nurse managers to acquire the knowledge, skills and confidence to prevent and reduce incivility.

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Background: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work: Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations: This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration: This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a 'realist review', which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature ­ not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour.

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BACKGROUND: In an era marked by rapid technological advancements, changing demographics, and evolving healthcare needs, the landscape of health services has been undergoing a profound transformation. Innovation has emerged as a central force driving change in the healthcare sector, as stakeholders across the globe strive to enhance the quality, accessibility, and efficiency of healthcare services. OBJECTIVE: Within this dynamic context, this systematic literature review explored the barriers and driving forces behind successful health service innovation. METHODS: A comprehensive systematic literature review was conducted using the Griffith University Library search engine and databases that included PubMed, ProQuest, Web of Science, Scopus, and CINHAL. To achieve the study goal, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the associated PRISMA checklist guided the review and reporting method. RESULTS: Findings from this review identified a need for a universal definition of health innovation that encompasses the unique complexities and challenges within this context. In our comprehensive analysis of healthcare innovation, we have uncovered pivotal findings that underscore the indispensable nature of a well-structured framework. CONCLUSIONS: To succeed in fostering innovation within the health and social care sectors, it is imperative to establish an overarching organisational culture that meticulously addresses the following key components: team challenges; communication and collaboration; governance goals and authentic leadership, environmental engagement; and innovation endurance. Through systematic analysis of existing literature, this review offers a definition of health innovation, covering its conceptual foundations, determinants, and barriers, and provides a framework for creating an innovative culture.

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Effective integration of research within healthcare organisations is recognised to improve outcomes. A research strategy within a hospital Trust in South West England was revised, following the launch of a national Chief Nursing Officer (CNO) strategy that promotes research engagement and activity. The aim was to develop, implement and evaluate this revised strategic plan for research. High-level engagement within the organisation was established and previous initiatives evaluated. A 6-year plan with 2-year targets was defined and evaluated at year end. The four pillars of the CNO strategy were central to the revised strategy, underpinned by digital innovation. Evaluation of the earlier strategy indicated excellent engagement with the Chief Nurse Research Fellow initiative and the Clinical Academic Network. The 'Embedding Research In Care' (ERIC) unit was reconfigured to an ERIC model, which aided question generation and project development. Year one objectives were achieved within the revised plan. Implementing a research strategy within an organisation requires a cultural shift and a long-term vision is required with measurable objectives. The team demonstrated significant progress through high-level leadership, mentoring and cross-professional collaboration.

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INTRODUCTION: This research, conducted by a non-Aboriginal, White researcher, examines how health professionals working in remote Aboriginal communities engage with antiracism as instructed by national standards, whether strong emotions are elicited while reflecting on these concepts, and how these reactions impact on antiracist professional practice. METHODS: Eleven non-Indigenous allied health professionals were interviewed in a semi-structured format. Interviews were transcribed, thematically analysed and compared to existing literature. RESULTS AND DISCUSSION: Every participant identified overwhelming emotions that they linked to reflecting on racism, White privilege and colonisation. Professionals reported grappling with denial, anger, guilt, shame, fear, anxiety and perfectionism, loss of belonging, disgust and care. They reported that these emotions caused overwhelm, exhaustion, tensions with colleagues and managers, and disengagement from antiracism efforts, and contributed to staff turmoil and turnover. CONCLUSION: Previously, these emotional reactions and their impact on antiracism have only been described in the context of universities and by antiracist activists. This research identifies for the first time that these reactions also occur in health services in Aboriginal communities. Wider research is needed to better understand how these reactions impact on health service delivery to Aboriginal communities, and to evaluate ways of supporting staff to constructively navigate these reactions and develop antiracist, decolonised professional practice.

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Effective communication within nursing and multiprofessional healthcare teams is essential to promote patient safety. However, communication is a complex concept comprising various elements and variables that affect how messages are delivered, received and interpreted. In this article, the author explores communication within healthcare teams and provides some insight into the factors that affect team communication, such as interpersonal relationships. The author also explores organisational culture and cultural sensitivity, and discusses some evidence-based approaches to enhancing communication within healthcare teams.

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BACKGROUND: Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB. METHODS: A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust. CONCLUSION: Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB. STUDY REGISTRATION: This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

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Healthcare organisations implement a range of staff well-being initiatives and increasingly focus on compassionate leadership. While formal interventions aimed at maintaining and enhancing staff well-being can be beneficial, they have practical limitations, such as staff turnover and challenges in meeting demand. Therefore, everyday conversations between nurses in leadership positions and their team members also have an important role in supporting staff well-being. One psychological model that nurse leaders may wish to use is acceptance and commitment therapy (ACT), which involves techniques such as mindfulness, acceptance and values clarification. This article outlines the principles of ACT and explains how leaders can use these to guide well-being conversations with staff.

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Background: Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported. Aims: The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors. Methods: The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis. Results: Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting. Conclusion: The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.

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BACKGROUND: Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. METHODS: This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. CONCLUSIONS: Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. STUDY REGISTRATION: This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

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BACKGROUND: There is increasing emphasis in the UK on developing a nurse, midwife and allied health professional (NMAHP) workforce that conducts research. Training for clinical academic careers is provided by the National Institute for Health and Care Research (NIHR). However, the low number of successful applicants suggested there were barriers to achieving this. The Centre for Nursing and Midwifery Led Research (CNMR) launched a fellowship programme in 2016 to backfill two days a week of NMAHPs' time for up to a year, to give them time to make competitive applications to the NIHR. AIM: To report a study evaluating the CNMR fellowship programme. DISCUSSION: The making Visible the ImpaCT Of Research (VICTOR) tool ( Cooke et al 2019 ) was developed to describe the organisational impact of research. The 2016-17 CNMR fellows completed VICTOR and their responses were analysed using a framework approach. The analysis found the main benefits of participating in the programme were protected time for research, opportunities to develop collaborations, increasing intra- and inter-professional awareness of NMAHPs' research, peer-reviewed publications, and conference presentations. Challenges included a lack of support from line managers, limited value placed on NMAHPs' research and failure to backfill posts. CONCLUSION: There were some challenges with the fellowship programme, but all recipients found it to be a positive experience and undertook significant scholarly activity. IMPLICATIONS FOR PRACTICE: A contractual agreement must be established to foster committed partnerships between higher education institutions (HEIs) and the NHS. HEIs and the NHS should conduct frank discussions of the challenges encountered in fellowship programmes. Positive initiatives and outcomes in tertiary education and clinical settings should be shared to improve fellows' experiences and enhance partnerships between HEIs and the NHS. Job descriptions should include time allocation to review fellowship candidates' applications regardless of outcome. The showcasing of research successes and the benefits of NMAHP research must evolve to secure organisational 'buy in', which is the precursor to widening access to clinical academic pathways.

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BACKGROUND: In the Netherlands, newly qualified midwives start work as registered midwives without any formal transition support. Research shows that newly qualified midwives do not feel sufficiently confident and competent in their work during the period following graduation. This could impact the quality of care provided by newly registered midwives. The aim of this study is to seek consensus with stakeholders concerning viable components of support for newly qualified midwives working in midwifery care in the Netherlands. METHODS: A Delphi study was conducted among maternity care stakeholders in the Netherlands. During two rounds, sixteen statements derived from a theoretical framework of organizational socialization theory and previous studies were assessed (round 1, n = 56; round 2, n = 52). Stakeholders (N = 61) were invited and completed an online questionnaire that included spaces for opinions and remarks. RESULTS: Stakeholders agreed about an introductory support period for newly qualified midwives, involving performance feedback and regional-level backup from fellow midwives during shifts. They further agreed on the responsibilities of established professionals that they should support newcomers in practice and provide mentoring or group coaching, although they face organizational barriers for supporting newcomers. CONCLUSIONS: Stakeholders found consensus upon several components of support at the workplace. In addition, a stable work environment seemed less important in their opinion while previous research suggests otherwise. Practice organisations need to improve the employment conditions and support for newly qualified midwives to ensure the quality of midwifery care is guaranteed.

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BACKGROUND: This study aims to provide researchers and practitioners with a more elaborate instrument to measure turnover intentions based on the planned behaviour theory model. The questionnaire assesses 5 distinct aspects of turnover intentions (i.e., subjective social status, organisational culture, personal orientation, expectations, and career growth). METHODS: In this cross-sectional study (comprise of 2 studies in one) a wave survey design was applied to a large diversity of workers drawn from the staff of universities, banks, hospitals, factories, and telecommunication companies. Exploratory factor analysis (EFA) was applied the identify the sub-dimensions and Cronbach's alpha to assess the reliability of the first study. In the second study, for the Confirmatory factor analysis to establishing structural model of the dimensions. RESULTS: We demonstrate the reliability, factor structure, and validity evidence based on internal structure and relationship with other variables of the new measure among two samples (N1 = 622; N2 = 433). Twenty-five items with 5 factors were extracted to represent a broader perspective of turnover intention scale. CONCLUSIONS: In total, the study indicates that the assessment can be used to reliably assess several major indicators of turnover intentions. Therefore, improved employees' evaluations and reduced loss of valuable staff as a result of avoidable measures in considering the interests of workers.

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CONTEXT: The gradual impact of the Covid-19 pandemic had important effects on routines in surgical environments. In order to cope with the impact and re-establish anaesthesiology and surgery procedures, it was imperative to pursue in-depth studies with a view to ensuring safe surgical care, reducing hazards, as well as protecting the health, safety and wellbeing of the health personnel involved. The purpose of this study was to evaluate quantitative and qualitative approaches to domains of safety climate among multi-professional staffs of surgical centres during the Covid-19 pandemic and to identify intersections. METHODS: This mixed-method project employed a concomitant triangulation strategy on a quantitative approach in an exploratory, descriptive, cross-sectional study, as well as a qualitative approach by way of a descriptive study. Data were collected using the validated, self-applicable Safety Attitudes Questionnaire/Operating Room (SAQ/OR) questionnaire and a semi-structured interview script. The 144 participants were the surgical, anaesthesiology, nursing and support teams working in the surgical centre during the Covid-19 pandemic. RESULTS: The study found an overall safety climate score of 61.94, the highest-scoring domain being 'Communication in the surgical environment' (77.91) and the lowest, 'Perception of professional performance' (23.60). On integrating the results, a difference was found between the domains 'Communication in the surgical environment' and 'Working conditions'. However, there was intersection by the 'Perception of professional performance' domain, which permeated important categories of the qualitative analysis. CONCLUSIONS: For care practice, it is hoped to encourage improved patient safety, educational interventions to strengthen the patient safety climate and promote in-job wellbeing on the job for health personnel working in surgical centres. It is suggested that further studies explore the subject in greater depth among several surgical centres with mixed methods, so as to permit future comparisons and to monitor the evolving maturity of safety climate.

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In the wake of the COVID-19 pandemic, nurses are experiencing increasing stress, burnout and mental health problems. The Advocating and Educating for Quality ImProvement (A-EQUIP) model of clinical supervision aims to support staff wellbeing, promote positive work cultures and improve patient care. Although a growing body of empirical evidence supports the positive impact of clinical supervision, several individual and organisational barriers may impede the implementation of A-EQUIP in practice. Organisational culture, staffing and workforce pressures all affect employees' ability to engage with supervision, and organisations and clinical leaders must consciously work to sustain lasting change.

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BACKGROUND: Patient safety is a priority for all healthcare organisations. Enhancing patient safety incident reporting practices requires effective leadership behaviours at all levels in healthcare organisations. AIM: To explore nurses' perceptions of the influence of nurse managers' leadership behaviours and organisational culture on patient safety incident reporting practices. METHOD: A descriptive, cross-sectional, correlational design was adopted with a convenience sample of 325 nurses from 15 Jordanian hospitals. RESULTS: Respondents had positive perceptions of their nurse managers' leadership behaviours and organisational culture. There was a significant positive relationship between leadership behaviours and organisational culture (r=0.423, P<0.001) and between leadership behaviours and actual incident-reporting practices (r=0.131, P<0.001). Additionally, there was a significant positive relationship between organisational culture and incident-reporting practices (r=0.250, P<0.001). CONCLUSION: Healthcare organisations must develop leaders who will foster a supportive and just culture that will enhance nurses' practice with regards to reporting patient safety incidents.

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PURPOSE: Healthcare organisations are often described as less innovative than other organisations, since organisational culture works against innovations. In this paper, the authors ask whether it has to be that way or whether is possible to nurture an innovative culture in a healthcare organisation. The aim of this paper is to describe and analyse nurturing an innovative culture within a healthcare organisation and how culture can support innovations in such a healthcare organisation. DESIGN/METHODOLOGY/APPROACH: Based on a qualitative case study of a healthcare unit that changed, within a few years, from having no innovations to repeatedly generating innovations, the authors describe important aspects of how innovative culture can be nurtured in healthcare. Data were analysed using inductive and deductive analysis steps. FINDINGS: The study shows that it is possible to nurture an innovative culture in a healthcare organisation. Relationships and competences beyond healthcare, empowering structures and signalling the importance of innovation work with resources all proved to be important. All are aspects that a manager can influence. In this case, the manager's role in nurturing innovative culture was very important. PRACTICAL IMPLICATIONS: This study highlights that an innovative culture can be nurtured in healthcare organisations and that managers can play a key role in such a process. ORIGINALITY/VALUE: The paper describes and analyses an innovative culture in a healthcare unit and identifies important conditions and strategies for nurturing innovative culture in healthcare organisations.

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The purpose of this research is to determine whether the Covid-19 pandemic has had an impact on the change of organisational culture in public high schools. Additionally, if there has been a change in organisational culture, to what extent does this change differ from the preferred type? Cameron and Quinn's OCAI questionnaire was used to determine the types of organisational culture. 453 valid responses were obtained from teachers of randomly selected public secondary schools in all regions of the Czech Republic. Pre-Covid-19, the present and preferred status were assessed. It was found that initially hierarchy culture was predominant, while currently preferences for adhocracy and market culture have increased significantly, although the hierarchy type still prevails. In the type of future, respondents will see the clan of organisational culture. The shift in each type, but also in each of its dimensions in the three periods studied, provides the researcher with a theme for deeper research into the context, and for school institutions and principals to develop strategies to support the creation of a healthy organisational culture.

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PURPOSE: The purpose of this paper is to describe the 4C's of Infuence framework and it's application to medicine and medical education. Leadership development is increasingly recognised as an integral physician skill. Competence, character, connection and culture are critical for effective influence and leadership. The theoretical framework, "The 4C's of Influence", integrates these four key dimensions of leadership and prioritises their longitudinal development, across the medical education learning continuum. DESIGN/METHODOLOGY/APPROACH: Using a clinical case-based illustrative model approach, the authors provide a practical, theoretical framework to prepare physicians and medical learners to be engaging influencers and leaders in the health-care system. FINDINGS: As leadership requires foundational skills and knowledge, a leader must be competent to best exert positive influence. Character-based leadership stresses development of, and commitment to, values and principles, in the face of everyday situational pressures. If competence confers the ability to do the right thing, character is the will to do it consistently. Leaders must value and build relationships, fostering connection. Building coalitions with diverse networks ensures different perspectives are integrated and valued. Connected leadership describes leaders who are inspirational, authentic, devolve decision-making, are explorers and foster high levels of engagement. To create a thriving, learning environment, culture must bring everything together, or will become the greatest barrier. ORIGINALITY/VALUE: The framework is novel in applying concepts developed outside of medicine to the medical education context. The approach can be applied across the medical education continuum, building on existing frameworks which focus primarily on what competencies need to be taught. The 4C's is a comprehensive framework for practically teaching the leadership for health care today.

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