Physicians are increasingly expected to lead teams, programs, and health care systems in contexts marked by growing clinical complexity, workforce distress, and persistent inequities. In response, physician leadership education has expanded across the education and career continuum; yet, well-being is often addressed as a parallel concern rather than as a core leadership responsibility. This article advances health-promoting leadership as a framework for understanding how leadership practices shape the conditions for health within medical learning and working environments. Informed by the Okanagan Charter and contemporary leadership scholarship, this article conceptualizes health-promoting leadership as a core, teachable competency that can guide physician leadership education. It describes key competency domains; outlines how health-promoting leadership can be cultivated across stages of training and practice; and identifies institutional responsibilities for aligning leadership education, governance, and accountability with the creation of healthy, equitable, and sustainable health care environments.

KEY WORDS: health promotion, leadership education, Okanagan Charter

Do V. Health-promoting leadership as a core competency across the physician leadership education continuum. Can J Physician Leadersh 12(1): 31-42. https://doi.org/10.37964/cr24804

Over the past decade, physician leadership education has gained increasing prominence across undergraduate, postgraduate, and continuing professional development contexts. Leadership programs commonly address domains, such as change management, quality improvement, negotiation, and organizational governance, reflecting the growing recognition that physicians play influential roles within health care systems.¹ At the same time, physician burnout, moral distress, and workforce strain have been widely identified as pressing challenges with implications for health care quality, system sustainability, and patient safety.²

These parallel developments have created an important opportunity to examine more closely the relation between leadership and health in medical learning and working environments. Leadership is increasingly understood as shaping not only organizational performance, but also the everyday conditions in which physicians learn, work, and provide care. Decisions related to workload, team functioning, communication, and resource allocation influence psychological safety, trust, and well-being, and they accumulate over time to shape professional identity, team culture, and system sustainability.³ Leadership practices, therefore, function as an important influence on health at individual, team, and system levels.

In many leadership curricula, well-being is addressed as a distinct or complementary topic, commonly through self-care strategies, resilience-building approaches, or optional wellness initiatives.¹ Although these efforts are valuable, they may not fully capture the ways in which leadership practices and organizational structures actively shape health. Physician leaders are frequently encouraged to support well-being without explicit attention to how leadership itself functions as a mechanism through which health is promoted or undermined in clinical and educational environments.

The Okanagan Charter⁴ offers a useful and underused framework for addressing this gap in physician leadership education. The charter articulates interrelated action areas that emphasize embedding health into institutional culture, fostering health-promoting environments, supporting personal and collective well-being, promoting community engagement, advancing research and scholarship, and aligning leadership and governance with health promotion. Although developed for academic institutions, the charter’s principles align closely with the realities of medical education and health care organizations, where leadership decisions shape learning environments, workplace culture, and the conditions for health.

Health-promoting leadership provides a way to translate the Okanagan Charter’s strategic directions into leadership education and practice. By emphasizing how leadership practices influence environments, relationships, and systems of care, health-promoting leadership positions well-being as an outcome of intentional leadership action rather than an individual responsibility alone. In this article, we explore how health-promoting leadership, informed by the Okanagan Charter, can guide physician leadership education across the continuum of training and practice.

Defining health-promoting leadership in medicine

Health-promoting leadership can be defined as leadership practice that intentionally creates, sustains, and repairs the conditions that enable psychological, social, and organizational health.⁵ Rather than focusing narrowly on individual well-being interventions, health-promoting leadership attends to how culture, power, relationships, policies, and learning environments shape health outcomes for learners, clinicians, and patients. This framing shifts attention from individual coping to the broader institutional and relational contexts in which health is produced.

In medical contexts, health-promoting leadership is enacted through everyday leadership actions. This includes how leaders structure work and learning environments; respond to error, uncertainty, and vulnerability; and distribute power, voice, and recognition within teams. It also encompasses how leaders address inequities embedded in systems and practices, and how they align stated values with operational decisions. These leadership practices directly shape whether clinical and educational environments foster trust, psychological safety, and belonging or contribute to distress, disengagement, and moral injury.

The Okanagan Charter provides a useful lens for conceptualizing these leadership actions. It has been adapted to the medical context to emphasize creating supportive environments, integrating health into organizational culture, and aligning leadership and governance with health promotion.⁶ Health-promoting leadership operationalizes these principles by translating them into leadership competencies that can be taught, practised, and evaluated in medical education and leadership training programs.

Health-promoting leadership is distinct from traditional leadership competencies. It does not replace skills, such as strategic planning or financial stewardship. Instead, it reframes their purpose by recognizing that decisions related to efficiency, performance, and change carry consequences for health. Within this orientation, leaders are accountable not only for organizational outcomes, but also for the health effects of the environments they create.

Health-promoting leadership is not synonymous with wellness programming. It represents an ethical orientation to leadership practice that recognizes leadership as a mechanism through which health is either produced or eroded within health care systems. By making these dynamics explicit, health-promoting leadership offers a foundation for physician leadership education that aligns closely with the Okanagan Charter’s vision of institutions as settings that actively promote health.

Why health-promoting leadership must be developed across the continuum

Leadership identity and leadership practice are often shaped before physicians assume formal leadership titles.⁷ From the earliest stages of training, physicians are exposed to implicit and explicit messages about authority, hierarchy, endurance, and professionalism through role modeling and the hidden curriculum.⁸ How supervisors respond to mistakes, how clinical workload is justified or normalized, and how learner vulnerability is acknowledged or dismissed all function as powerful lessons about leadership. These experiences contribute to deeply ingrained assumptions about whose well-being matters, how power should be exercised, and what forms of behaviour are rewarded in medical environments.

When health-promoting leadership is introduced only in mid- or late-career leadership programs, physicians may already have internalized leadership norms. In contrast, leadership education that explicitly names leadership as a determinant of health from the outset supports physicians in recognizing their influence across a range of contexts, including situations in which they do not hold formal authority. Embedding health-promoting leadership across the physician education and career continuum supports coherence among what physicians are taught in formal curricula, what they observe in clinical settings, and what they are ultimately expected to enact as leaders.

Core competency domains for health-promoting leadership

To meaningfully integrate health-promoting leadership into physician leadership education, programs must move beyond aspirational language and articulate clear, teachable competency domains. Without explicit competencies, leadership education risks positioning health and well-being as values rather than as skills that can be developed, practised, and evaluated. The Okanagan Charter provides a useful organizing framework for this work. Drawing on these principles, here are five proposed interrelated competency domains that should be intentionally embedded across leadership curricula and revisited at various stages of the physician education and career continuum.

1. Creating healthy learning and working environments

Health-promoting physician leaders require the ability to recognize how organizational structures, policies, and workflows shape health in learning and care environments. This includes understanding how workload design, scheduling practices, supervisory expectations, and evaluation systems influence psychological safety, chronic stress, and sustainability over time. Leadership education should support physicians in developing the capacity to identify environmental contributors to distress and disengagement, rather than attributing challenges solely to individual limitations. This domain closely aligns with the Okanagan Charter’s emphasis on creating supportive and health-promoting environments by equipping leaders with systems-thinking skills and the ability to redesign processes in ways that promote learning, recovery, and long-term workforce sustainability rather than endurance alone.

2. Relational leadership and trust stewardship

Trust is foundational to effective leadership and to the functioning of healthy clinical teams. Health-promoting leadership involves the capacity to build, maintain, and repair trust, particularly in contexts characterized by uncertainty, conflict, or harm. Physician leaders must be prepared to attend to how trust is influenced by transparency, consistency, follow-through, and responsiveness to concerns raised by learners and colleagues. Leadership education in this domain should address how trust is strengthened or eroded through everyday interactions, including how leaders communicate during crises, respond to feedback, and acknowledge mistakes. This competency reflects the Okanagan Charter’s focus on fostering supportive institutional cultures and strengthening relationships as a core mechanism through which health is promoted.

3. Power, equity, and inclusion in leadership practice

Leadership decisions inevitably shape how power, burden, and opportunity are distributed in health care environments. Health-promoting leaders must be able to recognize how power operates within teams and institutions and how structural inequities influence experiences of safety, belonging, and voice. Leadership education should move beyond a narrow focus on individual bias to examine how policies, norms, and leadership practices can either perpetuate or disrupt inequity. This includes supporting leaders to reflect on whose perspectives are prioritized, whose labour is rendered invisible, and how decisions may differentially affect learners and staff from structurally marginalized groups. This domain aligns with the Okanagan Charter’s commitment to equity, diversity, and social justice as foundational to health-promoting institutions.

4. Modeling vulnerability and psychological safety

Physician leaders play a critical role in shaping whether vulnerability is perceived as a professional risk or as a foundation for learning and growth. Health-promoting leadership includes modeling uncertainty, reflection, and accountability, and responding to error in ways that support improvement rather than fear or blame. Leadership education should explicitly address how leaders’ responses to mistakes, questions, and expressions of distress signal what is safe to say and do within teams. By learning to model vulnerability appropriately and to foster psychological safety, physician leaders can create environments that support open communication, learning, and collective responsibility. This competency reflects the Okanagan Charter’s emphasis on cultivating cultures that support well-being and enable individuals and communities to thrive.

5. Accountability for health and well-being outcomes

Health-promoting leadership ultimately requires accountability. Physician leaders should be trained to consider health and well-being outcomes as meaningful indicators of leadership effectiveness, alongside traditional metrics related to productivity, efficiency, and performance. This includes the ability to interpret data related to workforce well-being, learning environment quality, and equity, and to integrate these considerations into strategic and operational decision-making. Leadership education in this domain aligns with the Okanagan Charter’s call to align leadership, governance, and institutional priorities with health promotion. This shift moves leadership education from supporting well-being as an ancillary concern to accepting responsibility for the conditions that produce health within systems, reinforcing health-promoting leadership as a core leadership function rather than an optional commitment.

Teaching health-promoting leadership across the continuum

The Okanagan Charter emphasizes that health promotion must be embedded across institutional roles, structures, and stages of engagement, rather than addressed through isolated or time-limited interventions. Teaching health-promoting leadership through the lens of the Okanagan Charter encourages educators to align leadership education with the creation of supportive environments, the integration of health into institutional culture, the advancement of equity, and the alignment of leadership and governance with health promotion. Table 1 provides a summary of the health promoting leadership competencies that can be prioritized at different stages of physician training and practice.

Undergraduate medical education: foundations and identity formation

In undergraduate medical education, leadership is often framed as a future responsibility associated with formal roles, rather than as a set of everyday practices enacted through interactions, teamwork, and responses to challenge. Health-promoting leadership education offers an opportunity to reframe leadership as something that is exercised daily, even by those without positional authority, and to situate leadership within the stewardship of learning and care environments. This approach aligns with the Okanagan Charter’s call to embed health into institutional culture from the earliest points of engagement.