Introduction Good leadership in surgery is fundamental to the delivery of quality patient care but is not formally taught in surgical training as it is in other high-risk professions and businesses. Presented here are evidence-based approaches to three key challenges faced by leaders in surgery. Challenge 1: Motivation of followers Problem: Low motivation and low morale decrease productivity, cooperation and patient safety. Leadership approach: Positive reinforcement of good behaviours improves employee enthusiasm and behaviour. An ‘engaging’ leadership model which openly values the knowledge and experience of their individual team members improves sense of belonging among team members, team performance and lowers burnout. Challenge 2: Power differential Problem: Surgical hierarchy can intimidate junior staff and impair team performance. Leadership approach: Power differential is used to empower followers and nurture confidence and curiosity. This enhances junior doctors’ own leadership and decision-making skills, and fosters a sense of self-determination, competence, and meaning in their work which leads to improved individual and organisational performance. Challenge 3: Trust and psychological safety Problem: Poor responses of leaders to mistakes increases likelihood of future errors and endangers patient safety. Leadership approach: Requires taking responsibility in the management of mistakes made by junior staff. A compassionate, rather than an angry, response of leaders to mistakes engenders follower loyalty and trust. Transformational leadership promotes trust and psychological safety, which in turn promotes ‘speaking up’ and patient safety.