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Abstract

Engagement is a key mechanism through which leadership development programs translate into sustained behavior change, yet leaders at different organizational levels may differ in how effectively they convert participation into applied engagement. PURPOSE: We tested whether an identical 6-session mental toughness (MT) intervention produced different engagement benefits for mid-level versus senior healthcare leaders after controlling for baseline engagement, participation, and MT. METHODS: Two cohorts of hospital leaders completed the same intervention (mid-level n=20; senior n=12) using identical measures. MT was assessed with the Mental Toughness Index, and engagement with the Employee Engagement Scale (Total, Cognitive, Emotional, Behavioral). Outcomes were collected at baseline and Sessions 2-6. Within-person change-from-baseline was analyzed using GEE (Gaussian, exchangeable correlation; clustered by participant) with predictors for cohort, session, and participation dose (cumulative sessions), including a cohort×dose interaction. Models controlled for baseline outcome, baseline MT, and concurrent MT, with false-discovery rate correction across engagement outcomes. A sensitivity analysis used endpoint ANCOVA at Session 6 controlling baseline, baseline MT, and total attendance. RESULTS: Leadership level significantly moderated Behavioral Engagement dose-response (β = -0.35, 95% CI -0.58 to -0.12, p = 0.0025, q ≈ 0.0099). Senior leaders showed a positive dose slope (+0.28 per session, CI -0.04 to +0.60), while mid-level leaders showed minimal change (-0.07, CI −0.34 to +0.20). No cohort×dose effects were observed for total, Cognitive, or Emotional engagement (p ≥ .35). Endpoint ANCOVA showed no adjusted cohort differences at Session 6 (p ≥ .23). CONCLUSION: Findings suggest MT training supports engagement broadly, with behavioral gains potentially varying by leadership level. The exploratory, hypothesis-generating findings indicate senior leaders may translate session participation into behavioral engagement more efficiently than mid-level leaders, and that tailoring engagement-focused interventions by leadership tier may enhance behavioral engagement among mid-level leaders in healthcare settings.

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