Hospitals are complex socio-political entities, and the ability for engagement and leadership among clinicians can be hampered by power dynamics, disciplinary boundaries, and competing discourses within the organization. The ten-sion inherent between clinical and administrative discourses is evidenced in the findings from the evaluation of clinical directorate structures in Australian hospitals, with close to two thirds of medical and nursing staff surveyed reporting the primary outcome of such structures was increased organiza-tional politics.48 At the same time as there have been growing calls for clinical leadership, there is evidence from Australia that reform and restructure within hospitals has resulted in a loss of nursing management roles and functions.49 Despite a policy agenda to foster clinical leadership, there are reports that managerial imperatives can instead primarily focus upon fiscal efficiency or organizational political imperatives, with various factors colluding to silence concerns of clinicians.