Understanding and enacting followership in an undergraduate medical exercise: A qualitative study

INTRODUCTION: Followership refers to the active, relational behaviors individuals enact when supporting, shaping, or influencing leadership from positions without formal authority. Although leadership dominates health professions curricula and scholarship, followership remains comparatively underexamined. This qualitative study explores how fourth-year medical students conceptualized and practiced followership during a high-fidelity, military medical simulation. METHODS: Seventeen medical students participated in semi-structured interviews within three weeks of completing the exercise. Interviews focused on students' experiences with leadership and followership during the exercise. Transcripts were analyzed using thematic analysis informed by a constructivist orientation to understand how students made meaning of their experiences. RESULTS: Three interrelated themes were constructed describing how students perceived and enacted followership during the simulation: (1) anticipating and providing proactive support for leaders; (2) knowing when to step up, step back, and speak up; and (3) maintaining calm and promoting team morale during stress. Students emphasized that followership was not passive obedience but a practice that influenced team performance, leader effectiveness, and psychological safety. Many also recognized how their followership behaviors shaped their leadership development, reinforcing the interdependence of these roles. CONCLUSION: Findings offer insight into how learners conceptualize and enact followership in high-fidelity simulation environments. Recognizing followership as distinct from leadership and teamwork, this study contributes to a more precise understanding of how trainees develop within team-based healthcare settings.