In the fast paced and emotionally intense world of healthcare, strong leadership is critical. Decisions made at the top can have lasting effects on patient care, staff morale, and even the future of the system itself. While much is written about leaders giving direction, less is said about the act of “leading up”, the courage and responsibility of those below management in healthcare to speak the truth to those in charge.
This blog explores what it means to lead up in the healthcare system, why it matters, and how healthcare professionals, especially those early in their careers, can find the strength to speak truth to power. Drawing insights from Thrust Into Leadership by Dr. Ian Alexander, we will also highlight the real struggles young professionals face when confronted with leadership challenges they may not be prepared for.
What is Leading Up?
Leading up means influencing those in authority by providing honest feedback, offering insights from the ground level, and advocating for better solutions even when it is uncomfortable. In the world of healthcare leadership, it can involve junior staff, nurses, residents, and even medical students addressing issues or concerns to senior doctors but the emphasis in this discussion is the need for new team leaders to “lead up” to department heads and hospital administrators.
While healthcare team leaders are trained to follow established policies and prioritize patient care, they also see the direct results of management decisions every day. Policies that look good on paper can fail in practice. Resources that seem sufficient from an office can be deeply inadequate in patient care units. When frontline workers speak up, they can bridge the gap between policy and practice. But it takes courage especially in a field where hierarchy is deeply embedded.
Why Speaking Truth Matters
Management in healthcare is not easy. Leaders must make difficult decisions, balance budgets, respond to regulations, and ensure patient safety. But no administrator can see everything. Mistakes or blind spots happen, and that is where speaking up becomes essential.
It is crucial for small team leaders to not only listen to input from their team members but when that input questions the status quo or policies that interfere with optimal patient care it is the responsibility of the team leader to act. If it is the consensus of the team that change is needed, by bringing the problem to the attention of administration, “leading up”, the team leader is an advocate for the team. This action demonstrates follow through and that the leader has the courage to act on the team’s behalf, strengthening the bond between the leader and the team. By being willing to listen, then act by “leading up”, the team leader establishes a culture that encourages those with less authority to feel safe sharing their concerns.
The Realities of Hierarchy
Unfortunately, many medical professionals feel unable to challenge those above them. This is especially true for students and trainees but also small team leaders who fear backlash, poor evaluations, or damaging their future careers. Dr. Ian Alexander In his book Thrust Into Leadership explores these dynamics in detail. He describes how new healthcare team leaders are often placed in situations without the tools or experience to succeed. Worse, when they recognize flaws in the system, they are often unsure how or whether to speak up.
Why Young Professionals Struggle to Leading Up
There are several reasons why new healthcare team leaders hesitate to speak truth to management:
- Lack of Experience: They may assume their observations are wrong or that someone else will address the issue.
- Fear of Retaliation: In tightly controlled environments, challenging authority can have career consequences.
- Cultural Norms: Many healthcare systems still reward obedience over innovation, especially from more junior staff.
- Imposter Syndrome: Young professionals often question whether they have the right to speak up at all.
Dr. Ian Alexander’s work helps shine a light on this struggle. In Thrust Into Leadership, he shows how leadership is not about titles or experience, but about responsibility. His message is clear: you do not have to be in management to lead.
Creating a Culture That Encourages Speaking Up
For true improvement in healthcare leadership, the environment must welcome and protect truth-tellers. Leading up should not feel dangerous. Hospitals and medical schools must make it clear that feedback, even when uncomfortable, is necessary and valued.
Here are a few ways management in healthcare can support leading up:
- Open Door Policies: Leaders must make time and space for honest conversations with staff at all levels.
- Anonymous Feedback Channels: When people cannot speak publicly, anonymous tools can help issues reach leadership.
- Psychological Safety: Team members should never fear punishment for raising concerns and small team leaders should not fear reprisal when advocating for change.
- Mentorship Programs: Senior professionals should guide younger colleagues not only in medicine but also in professional courage.
Practical Tips for Speaking Truth to Power
While the burden of creating a healthy environment falls on leadership, individuals can still take steps to speak truth respectfully and effectively.
- Choose the Right Time: Timing matters. Bringing up concerns during a crisis may not lead to productive outcomes.
- Focus on Facts: Stick to observations, data, and outcomes. Avoid personal attacks or emotional language.
- Propose Solutions: Leaders appreciate when someone brings a problem with a possible fix in mind.
- Document the Issue: If a concern is serious, keep a record of what happened and who was informed.
- Find Allies: Sometimes, a group of voices can be more powerful than one. Talk to others who may share your concerns.
The Role of Leaders in Listening
Healthcare leadership is not just about issuing orders or setting direction. It is also about listening. Leaders who welcome feedback are more likely to spot problems early, build trust with their teams, and create an environment where everyone can do their best work.
Management in healthcare should see every staff member, from the newest student to the most experienced nurse, as a potential leader. By listening actively and responding with empathy and action, leaders can show that speaking up is not only safe but essential.
A Final Word from Dr. Ian Alexander
Dr. Ian Alexander’s Thrust Into Leadership reminds us that leadership is often sudden, messy, and uninvited. Many in healthcare find themselves thrown into difficult roles, expected to make decisions and speak up without preparation. His book is a call to support these individuals with the training, mentorship, and culture they need to thrive. Most importantly, Dr. Alexander urges all healthcare professionals to see leadership as a mindset, not a position. Whether you are a student or a senior physician, you have the power and responsibility to influence the system for the better.
Conclusion
Leading up is one of the most powerful yet underappreciated forms of leadership in healthcare. It is not easy to speak truth to those in charge, especially in systems built on hierarchy and tradition. But if we want safer care, healthier workplaces, and better outcomes, we must create space for honest voices at every level. By following the guidance of thinkers like Dr. Ian Alexander and learning from real-world examples, we can build a future where leadership is shared, and every voice matters.
