Followership

OVERVIEW

Followership is a core competency that directly influences team performance, patient safety, and error prevention in critical care.

• Effective followers are active, engaged, assertive, adaptable, and able to shift fluidly between leading and following as situations evolve.
• High‑quality followership strengthens shared mental models, team adaptability, psychological safety, and mission‑driven collaboration
• Followership behaviours such as upward voice (“speaking up”), mutual performance monitoring, and backup behaviour are powerful protectors against clinical error.
• Whether effective followership occurs depends on contextual factors, such as leader effectiveness, and cultural and systems factors.

DEFINITION AND IMPORTANCE

Followership can be defined as the behaviours, skills, and attitudes that enables team members to contribute effectively to team performance, when they are not the positional leader.

• Critical care teams are interprofessional, dynamic, and time‑pressured; leadership shifts rapidly depending on patient needs.
• Effective followership is active, not passive — followers think critically, speak up, monitor teammates, and contribute meaningfully.
• Effective followers are central to team adaptability, team cognition, backup behaviour, and error prevention (Tannenbaum & Salas, 2020)
• Poor followership contributes to communication failures, team errors, and patient safety issues.

Followership is essential for shared leadership, distributed leadership, knotworking, and mission‑driven collaboration – all of which are commonly required in critical care:

Shared leadership (“leading together”)	More than one team member working together to collectively influence and guide the team’s actions, with leadership shifting fluidly based on expertise and situational need rather than formal authority.
Distributed leadership (“different leaders for different tasks”)	Leadership roles and responsibilities are intentionally spread across several team members so that influence, decision‑making, and coordination are shared rather than concentrated in a single individual.
Knotworking	Fluid teamwork where team members briefly take the lead, contribute, and step back again as the situation evolves, with no single fixed leader and constant re‑tying of roles, tasks, and expertise around the needs of the moment.
Mission‑driven collaboration	All team members aligning their actions, decisions, and communication around a shared goal.

COMPARISON WITH LEADERSHIP ROLES

Role	Definition	Key Features
Positional leader	The formally designated leader with role‑based authority	Organisationally assigned authority; accountable for decisions and coordination; allocates tasks and priorities
Non‑positional leader	A team member who momentarily guides the team’s next action based on expertise or situational factors, rather than rank	Provides brief, situational acts of leadership (“microleadership”); influence shifts fluidly; often emerges during dynamic clinical events
Follower	A team member contributing effectively when not the positional leader	Engages actively; speaks up; monitors teammates; supports shared mental models; performs backup behaviour

The positional leader does not always have the most influence on the team, influence may shift to non-positional leaders depending on the situation. Furthermore, roles performed by an individual can be fluid and context-dependent.

• E.g. An ICU senior registrar may be a follower on a consultant-led ICU ward round, the non-positional leader during resuscitation of a cath lab patient while the cardiology consultant is task-focussed on a procedure, and subsequently be the positional leader at a MET call on the ward.

EFFECTIVE FOLLOWERSHIP BEHAVIOURS

Team science has identified numerous behaviours that contribute to effective followership ((Tannenbaum & Salas, 2020):

Behaviour	Description
Mutual performance monitoring	Watching teammates for overload, task drift, or error and acting early.
Backup behaviour	Stepping in proactively to assist when someone is struggling or task‑saturated.
Upward voice	Speaking up assertively with concerns and suggestions.
Maintaining shared mental models	Keeping the team aligned through updates (“sitreps”), clarifications (“recaps”), and anticipation of next steps.
Adaptability	Shifting roles, tasks, and priorities as the situation evolves.
Team orientation	Prioritising collective goals over individual preferences.
Closed‑loop communication	Confirming messages to prevent error.
Psychological safety behaviours	Inviting input, acknowledging uncertainty, and respectfully supporting others in sharing perspectives.
Team reflexivity	Participating actively in debriefs to improve future performance.

HOW TO DEVELOP FOLLOWERSHIP COMPETENCIES

Followership competencies can be developed – and is done so most effectively when teams practice specific behaviours (Tannenbaum & Salas, 2020).

Team members can:

• Learn about effective followership behaviours (see above)
• Know the team mission – shared purpose improves collaboration.
• Maintain situational awareness – identify opportunities to update the team’s shared mental model
• Think critically – analyse information, question assumptions, offer alternatives (Kelley, 1992)
• Stay actively engaged
• Manage stress and regulate emotions
• Engage in effective learning methods (see below):

Learning Method	Definition
Simulation with targeted team behaviours	Scenarios designed to practise backup behaviour, upward voice, and shared mental models.
Guided debriefs	Structured reflection focusing on communication, role clarity, and adaptability. Can be performed after simulations and clinical events.
Behaviour‑based feedback	Specific, actionable feedback on observable team behaviours.
Recurrent practice	Repeated exposure to team‑based tasks to build automaticity.
Cross‑training	Learning each other’s roles to improve mutual monitoring and backup behaviour.
Pre‑briefing rituals	Establishing shared mental models before team actions (e.g. prior to trauma patient reception).
Psychological safety training	Practicing how to invite input, challenge respectfully, and respond constructively.

Educators and senior clinicians can assist learners in the following ways:

Teach followership explicitly	Simulation scenarios requiring specific followership skills; reminders about followership behaviours before clinical encounters; discussing followership skills during clinical event debriefings.
Role‑model followership behaviours	Demonstrating role‑switching by stepping into follower roles; showing effective followership behaviours during clinical encounters.
Teach communication frameworks	Using SBAR, graded assertiveness, and closed‑loop communication (etc) to support upward voice and shared mental models.
Frame followership positively	Addressing negative perceptions (e.g., misconceptions that followership is “cult‑like”); reframing followership as active, critical, and protective of patient safety.
Promote team reflexivity	Normalising and encouraging team debriefs; providing guidelines and cognitive aids for clinical event debriefing.
Develop competency frameworks	Incorporating followership behaviours into curricula, assessment, and professional development pathways.

HOW TO ENABLE FOLLOWERSHIP IN THE WORKPLACE

Whether effective followership occurs in the workplace also depends on contextual factors including leadership behaviours, systems, and culture. 

Leadership behaviours that facilitate effective followership (many of which flatten the power hierarchy):

Leadership Behaviour	Description/ example
Inviting upward voice	Actively asking for concerns, alternatives, and checks.
Modelling humility	Acknowledging uncertainty and welcoming correction.
Creating psychological safety	Rewarding input and responding constructively to challenge.
Setting clear expectations	Defining roles, responsibilities, and communication norms.
Running structured pre‑briefs	Aligning the team before action with roles, risks, and anticipated tasks.
Running structured debriefs	Reinforcing learning and team behaviours after events.
Supporting backup behaviour	Encouraging teammates to assist each other without stigma.
Clarifying the mission	Anchoring team actions to shared goals such as patient safety.
Modelling effective communication	Demonstrating closed‑loop communication, call‑outs, and inclusive language (“team, help me out here”).
Creating space for micro‑leadership	Stepping back to let others lead momentarily when they have the expertise.

Systems and cultural interventions that facilitate effective followership:

Intervention	Description/ example
Mission‑centred operating principles	Organisational emphasis on shared goals (e.g., patient safety) over positional authority.
Psychological safety norms	Explicit expectations that speaking up and questioning are valued and protected.
Flattened hierarchy practices	Cultural norms that allow any clinician to contribute or challenge based on expertise.
Structured pre‑briefing routines	Standardised huddles that establish roles, goals, risks, and shared mental models.
Standardised communication protocols and tools	Protocols (e.g., ISBAR, graded assertiveness, time‑outs) and tools (e.g., checklists, cognitive aids) that make responsibilities explicit and empower upward voice.
Support effective learning methods	Simulation with targeted team behaviours, guided debriefs, behaviour‑based feedback, recurrent practice, cross‑training, pre‑briefing rituals, and psychological safety training (see above)

FOLLOWERSHIP PITFALLS

Pitfalls for leaders

• Underappreciating the courage needed to speak up and overcome “hierarchy paralysis” if it is not facilitated by leaders and team culture
• Over‑ or under‑delegation
• Failure to recognise follower contributions
• Skipping prebriefs and/or debriefs after critical events
• Not championing systems/ cultural interventions and education programmes that facilitate effective followership

Pitfalls for educators

• Teaching leadership and teamwork without explicitly teaching followership
• Ignoring negative connotations learners associate with followership
• Not addressing followership behaviours in assessments and feedback sessions

Pitfalls for followers

• Passive obedience and lack of engagement
• Information hoarding and other behaviours that prioritise individual goals over team goals
• Token assertiveness (challenging inappropriately)
• Skipping prebriefs and/or debriefs after critical events
• Not practicing followership behaviours or engaging in effective team-based learning methods

MODELS OF FOLLOWERSHIP

The most relevant model of followership to critical care teams comes from team science (Tannenbaum & Salas, 2020)

• Followership consists of observable team behaviours that directly support team effectiveness.
• See above for “Effective Followership Behaviours”

Other models of followership provide insights into different aspects of followership in different contexts:

Kelley’s Followership Model (Kelley, 1992)	categorises followers into five behavioural “types” based on their levels of independent critical thinking and active engagement. Categories: exemplary, alienated, conformist, passive, pragmatist. Historically widely used, but the model is static, simplistic, focused on individuals not relationships, and does not apply well to fluid roles
Engagement Model (Kellerman, 2008)	classifies followers by their degree of engagement, ranging from completely disengaged to intensely committed. Lacks relevance to most clinical teams in action
Courageous Followership (Chalef, 2009)	emphasises followers’ responsibility to support leaders, challenge them ethically, and speak up courageously to protect the mission. Model is leader-centric and underemphasises culture and contextual influences
Implicit Followership Theory (Carsten et al, 2010)	explains how beliefs, culture, and context influence followership
Relational Followership Theory (Uhl‑Bien et al, 2014)	defines followership as a dynamic, co‑created relational process (rather than an individual trait) in which leaders and followers jointly produce leadership outcomes.

EVIDENCE

Description	Key findings	Commentary
Barry et al (2024): Narrative “state-of-the-art” review (48 studies) tracing historical evolution of followership in interprofessional healthcare teams.	Early literature: passive followers. Modern literature: active, critical, engaged followers. Persistent tension between old hierarchical models and new distributed models.	Strong historical synthesis; clarifies conceptual evolution. Narrative design; limited empirical data; heterogeneity of included studies.
Alanazi et al (2023): Scoping review (42 studies) mapping all followership research involving healthcare clinicians	Six categories of research: followership styles, impact, experience, features, assertive followership, interventions. 40% analytical studies; 31% qualitative; 12% interventional. Gaps: lack of competency frameworks, limited intervention studies, no longitudinal data, cultural influences under‑studied.	Comprehensive mapping; identifies major gaps; includes diverse professions. Heterogeneous definitions; variable study quality; limited actionable guidance.
Pathak & Wong (2022): Integrative review of followership concepts applied to healthcare team dynamics.	Followership is often misunderstood as passivity. Exemplary followers (Kelley model) = critical thinkers + active engagement + courage + discretion. Structured followership training recommended.	Clear practical recommendations; integrates multiple theories. Not an empirical study, extrapolates from non‑clinical fields.
Tannenbaum & Salas (2020): Evidence‑based synthesis of team effectiveness research for popular dissemination	Effective teams rely on backup behaviour, mutual performance monitoring, shared mental models, psychological safety, team adaptability, team reflexivity, upward voice, role clarity, and collective orientation. Followers are essential for preventing error, maintaining situational awareness, and supporting leaders. Team debriefs are one of the most powerful interventions for improving followership and team performance.	Highly evidence‑based; directly applicable to critical care teamwork. Not healthcare‑specific; requires contextual adaptation.

CONCLUSION

Modern teams require active, engaged, adaptable followers who think critically, perform effective followership behaviors, and shift roles fluidly. 

• Teams must participate in targeted learning activities to develop followership competencies (e.g. simulation, team reflexivity in the workplace)
• For effective followership to occur it must be facilitated by key leadership behaviours (e.g. actions that promote psychological safety) and systems and cultural interventions (e.g. team huddles and prebriefs, flattened hierarchy).
• Poor followership — including silence, passivity, information hoarding, hierarchy paralysis (absence of upward voice), and failure to monitor teammates — contributes to adverse events and preventable harm.

REFERENCES

LITFL

• Clinical debriefing 
• In situ simulation
• Psychological safety and simulation
• Simulation debriefing
• Speaking up

Journal articles and books

• Alanazi S, Wiechula R, Foley D. Followership in health care clinicians: a scoping review. JBI Evid Synth. 2023 Sep 1;21(9):1764-1793. doi: 10.11124/JBIES-22-00310. PMID: 37211993.
• Alwazzan L. When we say … leadership, we must also say … followership. Med Educ. 2017 May;51(5):560. doi: 10.1111/medu.13228. Epub 2017 Jan 24. PMID: 28120458.
• Barry ES, Bader-Larsen KS, Meyer HS, Durning SJ, Varpio L. Leadership and Followership in Military Interprofessional Health Care Teams. Mil Med. 2021 Oct 26;186(Suppl 3):7-15. doi: 10.1093/milmed/usab118. PMID: 34724052.
• Barry ES, Bader-Larsen KS, Meyer HS, Durning SJ, Varpio L. Leadership and Followership in Military Interprofessional Health Care Teams. Mil Med. 2021 Oct 26;186(Suppl 3):7-15. doi: 10.1093/milmed/usab118. PMID: 34724052.
• ​​Carsten MK, Uhl‑Bien M, West BJ, Patera JL, McGregor R. Exploring social constructions of followership: a qualitative study. Leadersh Q. 2010;21(3):543‑562. doi:10.1016/j.leaqua.2010.03.015
• Chaleff I. The Courageous Follower: Standing Up to and for Our Leaders. 3rd ed. San Francisco, CA: Berrett‑Koehler; 2009. [google books]
• Gordon LJ, Rees CE, Ker JS, Cleland J. Dimensions, discourses and differences: trainees conceptualising health care leadership and followership. Med Educ. 2015 Dec;49(12):1248-62. doi: 10.1111/medu.12832. PMID: 26611190.
• Kellerman B. Followership: How Followers Are Creating Change and Changing Leaders. Boston, MA: Harvard Business Press; 2008. [google books]
• Kelley RE. The power of followership. New York, NY: Doubleday; 1992. [google books]
• Pathak KA, Wong AK. Followership: The Missing Link in Surgical Leadership. Ann Surg. 2022 Jun 1;275(6):e740-e742. doi: 10.1097/SLA.0000000000005376. Epub 2022 Feb 17. PMID: 35185129.
• Tannenbaum SI, Salas E. Teams That Work: The Seven Drivers of Team Effectiveness. Oxford University Press; 2020. [google books] [[website]
• Uhl‑Bien M, Riggio RE, Lowe KB, Carsten MK. Followership theory: a review and research agenda. Leadersh Q. 2014;25(1):83‑104. doi:10.1016/j.leaqua.2013.11.007
• Varpio L, Teunissen P. Leadership in interprofessional healthcare teams: Empowering knotworking with followership. Med Teach. 2021 Jan;43(1):32-37. doi: 10.1080/0142159X.2020.1791318. Epub 2020 Jul 16. PMID: 32673138.