Sustained Leadership Practices and Behaviours Following Postgraduate Leadership Education: A Qualitative Study

ABSTRACT

Aim

To explore how postgraduate leadership education is translated into practice and how leadership practices and behaviours are sustained following completion of a leadership program.

Design

A qualitative exploratory study using an appreciative inquiry approach.

Methods

A single Health District, partnered with a regional university, offering a 12‐month leadership program, the Effective Leadership in Health Program.

Four semi‐structured group interviews were undertaken with 11 registered nurses (RNs) and allied health professionals. Data were audio‐recorded and transcribed before being analysed using thematic analysis.

Results

Four themes were revealed relating to how the learning was translated and sustained in clinical practice, namely, within (1) self, (2) others, (3) relationships and (4) sustained leadership. All participants agreed that their participation in the leadership program impacted on their subsequent approach to leadership in multiple contexts, relationships and interactions.

1. Introduction

Increasingly, significant attention has been paid to the importance of visible and effective nursing leadership, with evidence demonstrating the positive impact such leadership makes to patients, staff and organisations (Middleton, Jones, and Martin 2021; Page, Halcomb, and Sim 2021). Key international reports and inquiries have asserted that leadership development is vital in healthcare since ‘organisational culture is informed by the nature of its leadership’ (Francis 2013, p. 66), In healthcare environments immersed in change and chaos, with complex issues, leadership cannot be assumed. Leadership development requires both education to develop an evidence‐based understanding and the opportunity to practice and develop the knowledge and behaviours learned (Francis 2013; Garling 2008; World Health Organization 2016). Internationally, substantial funds are spent to educate and develop healthcare leaders, demonstrating the priority of leadership development (Watts, Steele, and Mumford 2019). However, there has been limited exploration of how this leadership education impacts the subsequent clinical practice of those undertaking it.

2. Background

Competency in leadership is essential and has been directly associated with health professionals' performance, work engagement and satisfaction, commitment, well‐being and retention (Alluhaybi et al. 2023; Dickson et al. 2022; Pattison and Corser 2023; Haoyan et al. 2023). Internationally, nursing leadership has been evidenced to contribute positively to patient outcomes, safety and care quality by supporting nurses' competence and confidence and ensuring nurses feel valued, heard, cared for and safe (Alsadaan et al. 2021; Dickson et al. 2024). Developing healthcare leadership continues to be a key priority of international peak bodies, including the World Health Organisation (WHO 2020).

Roles and titles do not make a leader, rather behaviours reflect leadership qualities. These behaviours can be learned and developed through formal leadership programs and supportive organisational culture (Kouzes and Posner 2023; van Diggele et al. 2020; Cardiff et al. 2020) and used to influence others. Formal postgraduate leadership education is advocated for healthcare leaders (Middleton, Jones, and Martin 2021; Onyura et al. 2019), as it interweaves theory, practice and reflection, to promote skill development (Winters et al. 2022; Dickson et al. 2022). Despite its potential benefits, formal postgraduate leadership education has been challenged as having translational gaps between the educational delivery and subsequent application of leadership principles and behaviours in clinical practice (Onyura et al. 2019; Page, Halcomb, and Sim 2021).

Research and theory often speak a different language and address a different set of objectives from those pursued by clinicians. This can in some ways account for challenges in implementing leadership education into clinical practice (Page, Halcomb, and Sim 2021). Despite this, at local, national and international levels, there remains a drive to promote leadership education as a strategy for strengthening healthcare policy and practice (Francis 2013; Garling 2008; World Health Organization 2016). To optimise translation, it is critical that academic partners work with healthcare organisations to ensure that leadership education is relevant and transferable to the clinical setting (Onyura et al. 2019; Winters et al. 2022).

In their sentinel report Garling (2008), spoke of the need to ‘design, institute, conduct and evaluate leadership training’ (p. 10). To date, the evaluation of the impact of leadership education has been given scant attention (Page, Halcomb, and Sim 2021), and it can be challenging to demonstrate outcomes of leadership training (West et al. 2015). This is particularly true in relation to measuring change in clinical practice, culture or patient outcomes (Page, Halcomb, and Sim 2021; West et al. 2015). Yet understanding how leadership education influences professional practice is vital to understanding its value and effectiveness.

In response to local needs, a School of Nursing in a regional Australian university partnered with a Local Health District to deliver a 12‐month leadership program, the Effective Leadership (in Health) Program (ELP). This interdisciplinary program has been operating since 2008 and enables shared learning, networking, diversity in expertise and opinion and harnessing leadership potential across health disciplines. Although the program has been in operation for over a decade, the essence of the content and delivery have been consistent. Learners gain an understanding of effective leadership characteristics and the diverse organisational environments in which leaders function. They are introduced to various leadership models and encouraged to explore their own inherent leadership traits. Since effective leadership involves understanding organisational culture, interpersonal relationships, processes and systems, these aspects are examined and analysed within the context of the Health Services environment. The program builds upon and applies Kouzes and Posner's research—a model that has consistently identified five practices of leadership over the past 30 years (Kouzes and Posner 2023).

The Effective Leadership Program is co‐facilitated by an academic lead (RM) and a skilled facilitator (SM, SP) from the Health District (South Eastern Sydney Local Health District, 2024). Details of the program setting and elements are reported elsewhere (see Middleton et al. 2023). This study adds to existing knowledge by exploring the application of theoretical knowledge and skills developed in the Effective Leadership Program into practice over time.

3. The Study

3.1. Aim and Objective

The aim of this study was to explore how postgraduate leadership education is translated into practice and how leadership practices and behaviours are sustained following the completion of the Effective Leadership Program.

4. Methodology/Methods

4.1. Design

A qualitative exploratory study was designed using an appreciative inquiry approach. Appreciative inquiry suggests that knowledge is formed through social and cultural interactions, relationships and dialogue (Cooperrider and Whitney 2005). This approach was used as appreciative inquiry aims to elicit information and experiences in a relational manner where stories are generated by participants that connect with emotions, uncover understandings and help to create purpose (Cooperrider and Whitney 2005). The paper is reported according to the CORE‐Q checklist (Tong, Sainsbury, and Craig 2007) (Data S1).

4.2. Study Setting, Sampling and Recruitment

Registered nurses (RN), registered midwives (RM) and allied health professionals who had completed the Effective Leadership Program since its inception were invited to participate. The inclusion criteria included all alumni given the relatively small numbers of graduates each year, the relative consistency of the program content and delivery and the desire to explore the translation of the education across time since the program was completed. All Program graduates were employed a single Local Health District. This district spans 468 square kilometres from central Sydney in the north to the Royal National Park in the south, encompassing nine hospitals (South Eastern Sydney Local Health District, 2024).

An email invitation was sent to all Effective Leadership Program graduates' work email addresses by an independent administration officer. This was followed by three reminder emails. The administration officer collected all consent forms and coordinated the booking of the group interviews. While emails were sent to 271 Effective Leadership Program graduates, it is not clear how many of these had moved employment, and so were not contactable for recruitment or were not able to access their emails during the recruitment period.

4.3. Inclusion Criteria

Any person who had completed the Effective Leadership Program since its inception in 2008 and was willing to consent was eligible to participate. All Program graduates were considered eligible at varying times since completion, creating opportunities to apply the knowledge and skills learned to workplace opportunities.

4.4. Data Collection

Eleven Effective Leadership Program graduates consented to participate, choosing one of four online group interviews that best suited their availability. Group semi‐structured interviews were chosen as, in social research, they enable participants to contribute to a better articulation of implicit interpretation of social events, such as the Effective Leadership Program (Frey and Fontana 2019).

Interviews were conducted between August—October 2022, using Microsoft Teams, by an independent facilitator who had no involvement in the Effective Leadership Program. This ensured no perceived power imbalance between Effective Leadership Program facilitators (RM, SM, SP) and participants.

Interviews were undertaken using the four‐phased inquiry process—discovery, envisioning, co‐creating and embedding of appreciative inquiry (Cooperrider and Whitney 2005). Interviews lasted from 43 to 61 min (Mean 50 min). Field notes were taken during each interview. No new data were emerging in the fourth interview, and so no further participants were sought. Braun and Clarke (2022, p. 28) recommend avoiding the term saturation, rather ensuring ‘information richness’ occurs. This was evident in our study by the completion of the fourth group interview. Hennink and Kaiser (2022) identify this can be attained in qualitative research at relatively small sample sizes, with four to eight focus groups considered adequate.

4.5. Data Analysis

Interviews were audio‐recorded and transcribed verbatim by an independent transcription company. Data were thematically analysed following Braun and Clarke (2022) reflexive thematic analysis approach. Three authors (RM, SM, SP) independently read through the de‐identified transcripts, familiarising themselves with the data and noting key impressions. They then met and discussed initial impressions before repeating the process of independent reading, looking for initial codes related to the research aim. The three authors met and condensed the codes into preliminary themes, which were then discussed and revised further until agreement was reached on final themes (Figure 1).

FIGURE 1.

Themes.

4.6. Ethical Considerations

This research was approved by the South Eastern Sydney Local Health District Human Research Ethics Committee (No: 2022/ETH01018). According to the Declaration of Helsinki (2013) (World Medical Association, 2013), voluntary written informed consent was obtained from all participants, who were asked to keep interview discussions confidential. All data were de‐identified before analysis, and participants chose a pseudonym.

4.7. Rigour and Reflexivity

Rigour through reflexivity is important throughout the qualitative research processes of data collection, recruitment and analysis. By moving back‐and‐forth between reflection and awareness, the researchers were able to promote rigour and make links with the identified philosophical principles underpinning this research. This was particularly important since three of the researchers had longstanding experience of facilitating the Effective Leadership Program and needed to practice reflexivity to ensure any potential bias or assumption did not cloud the research process.

5. Results

5.1. Participants

Of the 11 participants, nine (81.8%) were female, and five (45.5%) were registered nurses (Table 1). Six (54.5%) participants had completed the program since 2018.

TABLE 1.

Participant demographics.

Group	Gender	Year completed	Pseudonym	Profession
1	Male	2018	John	Nurse
	Female	2008	Brenda	Nurse
	Female	2016	Melissa	Allied health
2	Female	2019	Sara	Allied health
	Female	2020	Kim	Nurse
	Female	2013	Kathryn	Allied health
3	Female	2018	Gemma	Nurse
	Female	2019	Charlotte	Allied health
4	Female	2018	Amanda	Allied health
	Female	2014	Karen	Nurse
	Male	2017	Louis	Allied health

5.2. Themes

All participants agreed that their participation in the Effective Leadership Program impacted their subsequent approach to leadership. Four themes revealed how learning was translated and sustained into participants' leadership practice, that is, within (a) self, (b) others, (c) organisational and (d) sustained leadership (Figure 1). Figure 1 highlights the connection and relationship between themes, building from self through to sustaining practices that impact others and the organisation.

5.2.1. Self

The notion of linking theory to practice emerged as participants identified how underpinning theory continues to guide their everyday leadership habits: ‘the whole Kouzes and Posner leadership practices, I see myself embedding them into the things and the projects that I am doing and the benefit of each of them’ (Kim). Others noted how the theory was now embedded in their daily work, reinforcing skills and behaviours they were practising. For example, Kathryn stated: ‘Being able to use those skills (I learnt) in a practical way is really helpful, because I think you learn the theory and then you have some way of being able to try it out or sort of put it into practice. And so I now continue to be doing both of those things together’.

Embedding theory into the Effective Leadership Program and engaging participants in it through the workshops and assessments were described by some as helping them to know what type of leader they wanted to be and how this continued to influence their interactions with colleagues. As Sara described: ‘I've got a much stronger sense of who I am as a leader, and what my language is like, and how I speak, and how I interact with people and I'm very clear on my values’.

Participants realised the benefit to their practice of deeper learning informed by theory. They discussed how the program expected an immersion in theory—for workshop discussion and for assessments and how this challenged them to critically apply this to themselves, their teams and the orgnaisation more broadly. Valuing theory was also described in terms of pursuing a greater depth of learning and a desire to keep growing academically.

Since that course, I've gone—I've enrolled in the Master of Coaching Psychology… it kind of clarified for me the direction that I wanted to go in (Sara).

I did then continue on beyond ELP to do my Master of Health Leadership and Management through (university)… having not studied since finishing my pre‐registration degree, it was a great way to build my confidence in getting back into the space of writing in an academic way and also meeting some of the colleagues that were connected with the university as well (Melissa).

Many participants shared that completing the Effective Leadership Program impacted their sense of who they were as a leader, often due to the underpinning reflection that raised awareness within them. John stated that his self‐awareness ‘absolutely changed, not changed who I was, but I think I finally understood a lot more about myself. More than I think I had ever done in the past. And for me it really pushed me in a direction that I never thought that I would go in. I continue to practice in this way’. Similarly, Kim found that the Program ‘enabled that self‐reflection (in me)’and Brenda stated that ‘getting to know yourself as a leader was a really big part of that…—it (ELP) actually gave that, it gave us the language and the framework and the point of reference. I know who I am as a leader and how I want to continue working’. These, and other comments, were discussed as supporting their self‐development as a leader and in equipping them to lead others as they identified their values and explored these in relation to their leadership.

Several participants identified that raised self‐awareness following the Program increased their confidence as a leader. For example, Karen said: ‘For me personally, it boosted my confidence as a leader. And then I was able to have the courage to do things that maybe before I wouldn't have believed were possible or that I'd be capable of’. Similarly, Brenda identified that ‘It really gave me confidence to go outside my clinical area and what I was used to…’. Raised confidence to lead was noted as enabling them to view the world from others' perspectives. This facilitated a clear articulation of how these values could influence and support those around them, particularly by employing strategies learned in workshops.

5.2.2. Others

Participants shared how their approach to leading others had changed. Participants observed that they became more aware of how they listen to others and truly hear their perspectives, creating opportunities for richer and more meaningful conversations with colleagues. These interactions often led to enabling conversations, where colleagues and team members were asked empowering questions to foster a deeper understanding and help them find solutions to their issues. The Effective Leadership Program ‘enhanced my interpersonal skills, but it has certainly helped me to understand others and how to better work with others and how not to do to people but do with’ (John). Sara confirmed she had altered her approach significantly: ‘Having done that program, my lens is, I would say, much sharper now. When I'm working with teams or speaking with people, it's a lot more of a person‐centred inquiry, an appreciative inquiry approach and asking questions, curiosity and that idea of the psychological safety as well is really important’. This was echoed by Amanda who said, ‘(having) that mindset of intrigue (about others) has probably been the biggest learning from the program’.

Learning from the Effective Leadership Program influenced participants' ways of working with others. Karen reflected that, ‘being able to use the (Kouzes and Posner) leadership practices, in terms of enabling others, other leaders to think of ways that they can evoke change using the practices’ has changed the way she works with her colleagues. Participants identified that the leadership skills they had acquired and tools used to develop these skills impacted their interactions with others, for example, how to use empowering questions to foster richer conversations. By actively listening and using their ‘voice,’ they felt more capable of engaging with and leading teams.

What I've learnt is how do you get to a space in a short period of time that you can then move on to do the work you want to do together. And to me that's around developing trust and respect really early on (Kathryn).

It's helped me reflect, think about perspective, think about other people's leadership strengths and how they might be different to mine and using those within the team (Kim).

Participants noted learning around how their behaviour and actions can impact their team members and vice versa. Many had not previously considered the importance of creating an environment where team members feel comfortable speaking up, supporting each other, and sharing ideas. Some participants shared how their leadership practice has developed and motivated others: ‘the other thing I've been able to enable, for me and for others, is to be empowering. To promote people when they are doing a project or working on something just to help empower them to keep going or to strive further’ (Kathryn). Kim shared, ‘when you actually see the impact of your leadership inspire other people to do the same for their wards, that's really motivating’. Participants recognised the importance of acknowledging and praising colleagues, which positively impacted teamwork and contributed to a positive workplace culture.

The significance of ‘role modelling’ and leading by example is integrated into the workshops, with learning facilitated through discussion. Participants reported that this approach helped them influence their teams to be more open, build trust and form meaningful relationships. Louis indicated that, ‘It goes back to role modelling, the behaviours of Kouzes and Posner. Which, while we oohed and aahed and grimaced at reading it, they still hold strong to my own values. It sounds a bit cliché but it's true. I do often think about them. And so it's actually about role modelling those and embedding into my own behaviours that I demonstrate’.

5.2.3. Organisational

The impact of undertaking the Effective Leadership Program on the organisation was noted through individual progression and opportunity, building a stronger transformational workforce with the courage to change and take risks. Several participants attributed their career development to completing the program. For Brenda, completing the program ‘opened so many doors’, while Melissa described how she didn't think ‘I would be here if it weren't for that starting point to be honest…’. Additionally, Gemma described how the program ‘has led to opportunities that I may not have had before; it has shown people that I'm interested in leadership development, and I am now in a more senior role within my team and have opportunities for secondments to more senior roles’.

Values in action was identified by participants as a priority to ensure individual and organisational values aligned to create a strong foundation for trust and confidence of staff and patients.

I've become acutely aware of ensuring that my personal espoused values are aligning with my professional practice values … for me it was about aligning my values with the organisational values, and what that looks like in the workplace (Louis).

Knowing what your values are helps guide in terms of what you feel your leadership style is going to be like … I think everything that I'm doing isn't jarring with things that I believe in, and I think that is really key to being able to maintain a standard of leadership because it sits so well within my values (Kathryn).

Recognising the importance of involving team members in processes and decisions around values in action was identified as significant in fostering effective change.

5.2.4. Sustained Leadership

Participants identified that the leadership skills and knowledge from the Effective Leadership Program had evolved into a way of being: ‘I think I've used the tools that I've learnt [in ELP] everyday in some form. But now it's a lot more flexible and it's just a way of being for me now, I've one hundred percent used those principles’ (Brenda). Others shared how they try to sustain their learning and to work in ways that align with their learning experience by revisiting Effective Leadership Program concepts, tools and principles regularly: ‘I try to keep the practice alive every day as much as I can. And I think I always come back to some of those key principles that we learnt through Kouzes and Posner’ (Kathryn). John added, ‘I have this giant folder on my desk which is my ELP folder. And I have all the print, all the documents, all the tools, all my reflections. I have it there on the desk and I refer to it all the time. I go back and go ‘Oh that's right’.

When leading in this way, participants noted that it could be challenging and potentially isolating: ‘sometimes you sort of feel like you're talking a different language in the (ELP) space. I mean it's great that I talk the same language as others from the program, but you do sometimes feel like a bit of a fish out of water in your own day‐to‐day network, talking a language that others aren't familiar with’ (Amanda). Sara agreed about language, adding: ‘when I was talking even about ways of working for the first time in our department and what it is, some people going, ‘Ooh, gosh, this feels a bit touchy feely”. John commented that to engage others and sustain his leadership ‘you really need as many tools in that toolkit as possible to help enable you to connect with people and I think ELP provided that but it also provided that ability to understand perspectives’.

Not only was participants’ leadership developed and sharpened, but also patterns for lifelong growth, application and learning were discussed. Charlotte shared that daily she was continuing to use the learning from the Effective Leadership Program, noting impact on herself and others:

I continue to develop myself as a leader–using courage to step out of my comfort zone and use of feedback to further develop and continue to grow along the [leadership] continuum. With others—with my team and my extended team—how we can collaborate and be leaders together, the importance of teamwork and culture. I draw strength from them and learn from them. I see my role to support, empower and lead others on their leadership journeys.

This approach to leadership enables an appreciation of others' strengths and how to leverage them to build a cohesive team. By recognising and using strengths within teams and the greater organisation, diversity of opinion and approach is enhanced. Peer support was viewed as needed to help with this process, through ‘reflection and development. It's an ongoing process and it's really important to have people around you that you can share that with’ (Kim). Louis emphasised the ongoing role of the connections built throughout the program, ‘I've maintained those connections and they've enhanced my practice and certainly my leadership skills in picking people's brains, particularly when I'm struggling with things’.

6. Discussion

This study has explored how post‐graduate leadership education is translated into practice and how leadership practices and behaviours are sustained following the completion of a leadership program. Participants described how completion of the Effective Leadership Program impacted their leadership behaviours within ‘self’, ‘organisation’, ‘others’ and ‘sustained leadership’. Evidence of such sustained change in clinical and professional practice presents an important insight into the value of leadership education programs in nursing and healthcare.

Participants in this study spoke of increased confidence as a result of the leadership education. This was often attributed to a greater self‐awareness and enhanced leadership knowledge. With the Effective Leadership Program having reflective practice underpinnings, participants gained deeper insights into themselves using models and theory. Reflective practice has been noted as a key function of effective nursing leaders to enable a fuller understanding of self as a person and as a professional (Wilson, Crenshaw, and Yoder‐Wise 2022; West 2021). Self‐awareness enhances effective and person‐centred leadership through continual awareness and development of self, self in relation and in the nursing and healthcare context (Cardiff, McCormack, and McCance 2018). This needs to be coupled with a passion for lifelong learning and self‐development, and a perspective of moving from leader to leadership (Luedi 2022).

Findings of this study highlighted that both relationships and influence are important factors in leading others. With a raised self‐awareness also came an enhanced awareness of the perspectives of others and the importance of doing this. This person‐centred approach to relationships is based on building trust and mutual understanding, ideas grounded in contemporary leadership theory (Kouzes and Posner 2023). Kouzes and Posner's (2023) research, over four decades, demonstrates that leaders who spend the most time and energy developing supportive relationships with those they work with are viewed by their team as most effective, resulting in higher levels of engagement. Barton (2021) describes how inclusive leaders embody a leadership approach that appreciates diversity, invites and welcomes everyone's individual contribution and encourages full engagement with the processes of decision‐making and shaping reality. By leading in inclusive ways, leaders aim to create, change and innovate while balancing everybody's needs. Empowerment of nursing and healthcare professional staff through leadership engagement is a key variable in job satisfaction, organisational commitment and intention to stay (West et al. 2017). Building relationships as leaders creates belongingness, value and worth for both individuals and teams, with effective and inclusive relationships creating trust and acceptance in a safe learning environment (Barton 2021). Findings from this study reinforce that to earn trust, respect and support, leadership must involve collaboration between leaders and followers, as well as between people and systems constantly adapting to challenges. Leadership should be distributed across many levels of healthcare organisations to improve the patient experience and staff morale (Muls et al. 2015).

Relationships are stronger and more effective when built on shared values that are lived. This study highlighted ‘values in action’ in nursing and healthcare professionals’ leadership as a priority, where an individual values clarification‐guided participants’ leadership behaviours and style. Aligning personal values to organisational values and articulating these into practice require authentic and transparent leadership, helping individuals and teams to live the shared values. When this occurs, self‐integrity is affirmed and higher levels of staff commitment, engagement and satisfaction are evident (West 2021), that is, effective organisational culture ensues. Creating effective healthcare organisational cultures requires a conscious, collective approach to ensuring that the right nursing and healthcare professional leadership is in place to nurture the right values with the right behaviours (West 2021; Muls et al. 2015).

Given the growing complexity and requirement of healthcare professionals to drive change, it is imperative that leadership education and training focus on interactions between people at all levels (Servey, Hartzell, and McFate 2020). Leadership development should focus on developing individual performance to improve the performance of the nursing and healthcare team, organisation or system, and should include all health professionals (West et al. 2015). For truly effective organisational cultures, interdisciplinary leadership must be learned together so it can be practiced together in healthcare. This then encourages networks and relationships across disciplines, a key priority of healthcare globally (McLaney et al. 2022).

Being an industry‐based program has led to strategic partnership between a single health district and a University in the design and delivery of the Effective Leadership Program. This has enabled the translation of leadership theory into daily nursing and healthcare practice with interdisciplinary connections and networks made. This key strength of the Effective Leadership Program has enabled opportunity to influence complex healthcare systems that require knowledge, skills, vision and innovation that transcend single perspectives and discipline boundaries, contributing to a more unified approach to nursing care.

6.1. Strengths and Limitations

While this study involved a small group of graduates from a single leadership education program, it provides a unique insight into the impact of such education on the leadership practices of multidisciplinary clinicians over time. However, given that graduates had to volunteer to be involved in the research, it is possible that participants who were more motivated to engage in the research gained greater benefits from the program than those who did not respond. To provide depth and diversity of experience, all program graduates were invited to participate. The variation in time since each of the participants had completed the program may have impacted their recollections, confounding experiences and responses. Given the importance of practice change to improve patient care and health system outcomes, further longitudinal research should be undertaken following leadership education programs to track changes in practice and factors that impact this.

7. Conclusions

Leadership education opportunities enable leaders and future leaders to develop the skills, attitudes and behaviours that drive safe, compassionate and person‐centred healthcare delivery. However, it is important that leadership education is translated into changes in participants behaviours and work practices. This study has shown that an industry‐based leadership program can have a significant impact on the long‐term leadership behaviours of participants. Such a program can promote self‐awareness and provide opportunities for career development.

Author Contributions

Rebekkah Middleton: conceptualisation, methodology, formal analysis, investigation, data curation, project administration, writing – original draft, writing – review and editing; Suzanne Murray: conceptualisation, methodology, formal analysis, data curation, writing – original draft; Sally Peters: formal analysis, writing – original draft; Amy Montgomery: writing – review and editing; Elizabeth Halcomb: writing – original draft, writing – review and editing.

Ethics Statement

The authors confirm that this research was approved by the South Eastern Sydney Local Health District Human Research Ethics Committee (2022/ETH01018).

Conflicts of Interest

Middleton has been involved in setting up the program and delivering since commencement. Murray and Peters have been involved in the delivery of the program over the past 5 years. The authors declare no conflicts of interest.

Supporting information

Data S1.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.