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Strategic Leadership: The Essential Skills

• Paul J. H. Schoemaker,
• Steve Krupp,
• Samantha Howland

The storied British banker and financier Nathan Rothschild noted that great fortunes are made when cannonballs fall in the harbor, not when violins play in the ballroom. Rothschild understood that the more unpredictable the environment, the greater the opportunity—if you have the leadership skills to capitalize on it. Through research at the Wharton School and […]

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The more uncertain your environment, the greater the opportunity—if you have the leadership skills to capitalize on it. Research at the Wharton School and at the authors’ consulting firm, involving more than 20,000 executives to date, has identified six skills that, when mastered and used in concert, allow leaders to think strategically and navigate the unknown effectively. They are the abilities to anticipate, challenge, interpret, decide, align, and learn. This article describes the six skills in detail and includes a self-assessment that will enable you to identify the ones that most need your attention. The authors have found that strength in one skill cannot easily compensate for a deficit in another. An adaptive strategic leader has learned to apply all six at once.

The storied British banker and financier Nathan Rothschild noted that great fortunes are made when cannonballs fall in the harbor, not when violins play in the ballroom. Rothschild understood that the more unpredictable the environment, the greater the opportunity—if you have the leadership skills to capitalize on it. Through research at the Wharton School and at our consulting firm involving more than 20,000 executives to date, we have identified six skills that, when mastered and used in concert, allow leaders to think strategically and navigate the unknown effectively: the abilities to anticipate, challenge, interpret, decide, align, and learn. Each has received attention in the leadership literature, but usually in isolation and seldom in the special context of high stakes and deep uncertainty that can make or break both companies and careers. This article describes the six skills in detail. An adaptive strategic leader—someone who is both resolute and flexible, persistent in the face of setbacks but also able to react strategically to environmental shifts—has learned to apply all six at once.

• PS Paul J. H. Schoemaker is the former research director of the Wharton School’s Mack Institute and a coauthor of Peripheral Vision (Harvard Business Review Press, 2006). He served as an adviser to the Good Judgment Project.
• SK Steve Krupp is Senior Managing Partner at Decision Strategies International, Inc.
• SH Samantha Howland , a senior managing partner at DSI, leads its Executive and Leadership Development Practice.

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Strategic Leadership and Organizational Performance: A Critical Review of Literature

Effective strategic leadership is considered as a major ingredient for the successful performance of any organization operating in the ever dynamic and complex environment of the 21 st century. In the context of information uncertainty and resource scarcity, strategic leadership is required to confront the reality of environmental turbulence and a continuous need for appropriate organizational change in order to achieve performance goals. Most of the conceptual and empirical studies have shown that strategic leadership actions significantly influence performance. Despite its importance, studies have demonstrated that the influence of strategic leadership on organizational performance is contingent upon situational constraints or random effects. To date, very little empirical research has analyzed the direct and indirect relationship between strategic leadership, external environment, organizational change and performance. This paper seeks to unearth this research gap by critically reviewing relevant conceptual and empirical literature to bring out the possibility that the external environment and organizational change could influence the relationship between strategic leadership and organizational performance. The paper advances the emerging postulations which anchor a conclusion that the direct effect of strategic leadership on performance is contested and hence inconclusive due to possible moderating and mediating influence of the external environment and organizational change respectively. It is hoped that the paper's postulations would guide empirical research in various contexts to hasten addressing of the extant knowledge gaps.

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Strategic Leadership Models and Theories: Indian Perspectives

ISBN : 978-1-78756-260-8 , eISBN : 978-1-78756-259-2

Publication date: 16 July 2018

Bhattacharyya, S.S. and Jha, S. (2018), "Literature Review of Strategic Leadership Models", Strategic Leadership Models and Theories: Indian Perspectives , Emerald Publishing Limited, Leeds, pp. 19-27. https://doi.org/10.1108/978-1-78756-259-220181004

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Sustainable leadership and sustainable entrepreneurship: a systematic literature review

• Open access
• Published: 13 August 2024
• Volume 5 , article number  188 , ( 2024 )

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• Greice Kely Aragão Ribeiro 1 &
• João Leitão 2  

The article aims to assess the connection between sustainable leadership and sustainable entrepreneurship, by providing a framework based on the main findings of the clusters relating the effectiveness of that connection. Using the Web of Science databases and applying inclusion and exclusion criteria, 149 articles were retrieved and analysed. The bibliometric analysis was conducted using R-Studio software. The main findings unveil that sustainable leadership and sustainable entrepreneurship are interrelated concepts that play a key role in promoting responsible business practices and formulating solutions to contemporary socio-environmental challenges. The study’s main contribution lies in highlighting the importance of knowledge about sustainable leadership, sustainable entrepreneurship and their links. In practical terms, analysis of the connection between sustainable leadership and sustainable entrepreneurship reveals how the former plays an important role in promoting the latter, inspiring and supporting entrepreneurs in the adoption of sustainable practices, generating a positive socio-environmental impact as well as economic value for the firm. There is a need for more research on sustainable leadership, especially correlating its effectiveness in promoting sustainable entrepreneurship.

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1 Introduction

In recent years, the problematics of sustainability has aroused the interest of various groups in society, especially organisations. The most common definition of sustainability is the act of meeting present needs without jeopardising future generations, so that everyone has the necessary resources. That is, satisfying the needs of the current generation without compromising those of future generations [ 110 ]. There is a constant challenge to find mechanisms and strategies to optimize the process leading to a more sustainable world [ 41 , 63 , 64 ].

The relevance of the topics of sustainable leadership (SL) and sustainable entrepreneurship (SE) and their influences on organisations is increasingly evident. Organisational success and maximum performance depend on the role of leaders and entrepreneurs. Besides serving as a model for other employees, leaders and entrepreneurs are responsible for achieving a company’s vision and objectives [ 80 ].

The conceptualization of sustainable leadership arises from combining the concept of sustainable development with leadership [ 39 , 61 ]. The sustainable leader needs to create an appropriate organisational environment for sustainable develop to take place [ 30 , 36 ] and should focus on relationships inside and outside the company [ 2 ]. That is, the leader performs various roles simultaneously [ 2 , 77 ]. Sustainable leadership (SL) includes behaviour and practices that create lasting value for all stakeholders, including society, the environment and future generations [ 61 , 99 ]. Sustainable leadership goes beyond green transformational leadership and responsible leadership [ 61 ]. It means having the capacity for long-term decision-making, promoting systematic innovation, cultivating a loyal team of employees and providing high-quality products, services and solutions [ 10 , 61 ].

The first studies on sustainable entrepreneurship refer to the idea of joining the concepts of entrepreneurship and sustainable development, arguing that the notion of sustainable development is a significant opportunity for entrepreneurs and innovators [ 5 , 40 ]. From a perspective of sustainability, sustainable entrepreneurship is considered a means to achieve a more sustainable future [ 5 , 18 ] and to address complex social and environmental issues through implementing innovative solutions [ 5 , 90 ]. In this context, the sustainable entrepreneur should be open to opportunities related to sustainability, knowing how to build bridges between questions of sustainability and market needs [ 2 ].

Although there is a steady growth in the literature on sustainable leadership [ 14 , 16 , 29 , 30 , 36 , 39 , 47 , 48 , 49 , 61 , 67 , 76 , 80 , 99 ] and sustainable entrepreneurship [ 13 , 25 , 32 , 44 , 52 , 70 , 71 , 73 , 84 , 89 , 90 , 92 , 95 , 96 , 111 ], there are still significant gaps in the understanding of the association between leadership and entrepreneurship from a sustainability perspective. This gap highlights the need for in-depth research to clarify the interrelationship between these two fundamental concepts.

Given this scenario, this study aims to investigate the connection between sustainable leadership and sustainable entrepreneurship. Specifically, it seeks to answer the question: what is the nature of the relationship between sustainable leadership and sustainable entrepreneurship? Although some studies suggest that sustainable leadership acts as a mediator between social identity and strategic entrepreneurship, and that leadership and management practices, innovation, high quality and stakeholder consideration positively predict financial performance and sustainability in small entrepreneurial firms [ 61 , 97 ], detailed understanding of this dynamic is still limited. Therefore, this article sets out to fill this gap, contributing to a better understanding of how sustainable leadership can influence and enhance sustainable entrepreneurship. A summary of the literature is provided in the Appendix (see Table 11 ).

The article is structured as follows: the research methods section describes the approach to the systematic literature review, using the Web of Science database to obtain articles and the R-Studio (Biblioshiny) tool for data analysis. The results and discussion section makes a descriptive presentation of the articles selected and discusses the clusters identified, proposing a framework from reading of this work. The final section presents the conclusions, implications, limitations and future lines of research.

2 Research method

The study takes the form of a systematic literature review, to allow the maximum combination and critical, reflective and synthetic assessment of a large number of results regarding the subject studied [ 21 ].

Tranfield et al. [ 100 ] proposed a clear, reproducible methodology to summarise scientific research in a systematic review, aiming to produce reliable, impartial knowledge of a given topic. Carrying out the systematic literature review involves the following phases: planning the research; developing the research and presenting and discussing the results, being sub-divided as follows: defining the research question; choosing the data sources; selecting the key-words for the search; searching for, and storing the results; selecting articles from the abstract, according to inclusion and exclusion criteria; extracting data from the articles selected; assessing the articles; and summarising and interpreting the data [ 21 , 51 , 100 ].

2.1 Phase 1—Planning the research

Defining the research question, choosing the data sources and key-words for the search are fundamental steps in beginning a systematic review [ 21 ].

Here, the objective is to analyse selected scientific research on the subject of sustainable leadership and sustainable entrepreneurship, from the international publications available on the Web of Science (WOS) database.

Clarivate’s Web of Science (WoS) was chosen as the primary database because it is widely used and recognized for its extensive coverage of journals and articles that cover a wide range of research topics in different scientific fields [ 20 , 23 , 59 , 78 ]. Adding to the previous, it is also recognized as the most used multidisciplinary database for research on management and organizational topics, which makes it particularly suitable for this SLR [ 59 , 81 , 113 ].

The key-words for the search were in accordance with the research question defined: Leadership , Sustainable Leadership and Sustainable Entrepreneurship , extending those terms with an asterisk (*) .

2.2 Phase 2—Developing the research

Developing the research involves identifying and selecting academic articles, according to inclusion and exclusion criteria, followed by extraction of the data selected, assessing them carefully to create a synthesis of the information gathered [ 21 , 23 , 100 ].

To filter articles, the following criteria were used (Table  1 ): selected key-words, document type ( Article ), Web of Science categories ( Management—Business—Business Finance—Economics—Public Administration ) and languages ( English ).

Although the literature contains various articles addressing entrepreneurship, leadership and sustainability, this study adopted the selection criterion of articles addressing the relation between sustainable entrepreneurship and sustainable leadership. Therefore, studies that did not explicitly adopt this perspective were excluded.

In order to guarantee a perfectly transparent approach to the preparation of this SLR, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol were used [ 69 , 103 ]. Figure  1 summarises all the steps followed in the data-collection process.

PRISMA Diagram—Selection and analysis of articles. Source: Adaptation from [59, 78]

The initial search in the WoS database identified 1516 documents associated with the keywords of the topic studied. After applying inclusion and exclusion criteria, the number was reduced to 504 documents. A detailed analysis, which included a review of titles, keywords and abstracts, identified 149 potentially relevant scientific articles.

The data was extracted from the selected articles and exported in plain text (txt) and Excel spreadsheet (xls) formats to form the database. Bibliometric analyses were carried out using the R-Studio/Biblioshiny software tools, which integrate network analysis and bibliometric visualisation functions [ 8 , 105 ]. The conceptual structure that represents relationships between concepts or words in publications was used to form clusters, using R-Studio's factor analysis (Biblioshiny). This made it possible to identify, in map form, the articles that contribute most to the topic and the most cited [ 94 ].

3 Results and discussion

Analysis of the results is the third phase of the systematic literature review process, with synthesis and interpretation of the data [ 21 , 51 , 100 ]. This section presents and analyses the results found using R-Studio (Biblioshiny) software for the bibliometric analyses.

3.1 Descriptive data analysis

Turning to the bibliometric analysis, the synthesis of the bibliographic data of the selected articles shows that the average document citation is 42, 97, in a universe of 379 authors, with a co-authorship index of around 2, 81. Figure  2 represents annual scientific production and average citation of articles per year.

Scientific production and average citation per year

A constant growth in publications on the topic is observed from 2007 to 2023, increasing more from 2018, with 2021 and 2022 having 28 and 27 articles, respectively, on sustainable leadership and sustainable entrepreneurship, emphasizing the topical nature of the subject.

The articles published in 2007 had an average annual citation of 42, 16, showing the relevance of these studies for new research in the following years. Also standing out are the articles published in 2010 and 2011, which had an average annual citation of 27, 41 and 25, 81 respectively.

Table 2 shows the fifteen most cited articles in total, providing information on the author and year of publication, the methodology used, the total number of citations (TC), the journal, the ABS Journal Guide 2021 (AJG2021) ranking, the impact factor (IF) and the publisher house of the journal.

Table 3 shows the most relevant publishing sources. The most prominent journals are Business Strategy and the Environment (BSE) with 10,74% and Small Business Economics: An Entrepreneurship Journal (SBEJ) with 4,7% of the 149 articles selected, in a universe of 77 journals. Of the other 62 journals, 52 have only one publication and 10 have 2 publications each.

Table 4 shows the most prolific authors on the subject, considering the number of articles published by each. The author’s impact is calculated by the H index conceived by Hirsch as a way of characterising scientific production and the researcher’s impact. It is obtained by the H number of publications cited by the author having at least H citations [ 27 , 42 , 94 ].

Figure  3 presents the word cloud. This is a graphic representation of the authors’ key-words appearing most frequently in the articles, based on application of Zip’s law [ 27 , 94 ].

The first five terms of sustainable entrepreneurship (59), sustainability (25), entrepreneurship (23), sustainable development (18) and sustainable leadership (10) were followed by leadership (7 ) and smes (5), confirming the effectiveness of the string. Although occurring less frequently (4) than the other terms, also indirectly related to the subject are: entrepreneurial ecosystem, entrepreneurial ecosystems, entrepreneurial intention, innovation, motivation, sustainable, triple bottom line and university. Other terms indicate the subject’s association with other areas: climate change, corporate sustainability, education for sustainable entrepreneurship, entrepreneurial orientation, firm performance, start-ups, sustainability orientation, sustainable entrepreneurial intentions, sustainable performance, transformational leadership and others .

Figure  4 shows the evolution and growth of the key-words in the period 2007–2023. Of the articles analysed here, the words of “sustainability” and “entrepreneurship” already appeared in 2007. The first studies related to the topic of sustainable entrepreneurship appeared in 2010. Sustainable leadership appears from 2014 onwards, while sustainable development emerges in 2017.

Growth of key-words

Evolution and growth of the key-words is noted from 2018, especially sustainable entrepreneurship, while references to sustainable leadership are still scarce.

3.2 Cluster analysis

To form clusters, the conceptual structure representing the relations between concepts or words in a set of articles was adopted, using the factor analysis of R-Studio (Biblioshiny) software. This identifies, in map form, the articles contributing most to the subject and the most cited. The diagram identifies the link between the topics and the documents [ 94 ].

The study used the bibliometric techniques of Multiple Correspondence Analysis, Field (Abstracts) and N-Grams(Unigrams), resulting in five clusters from the 149 articles selected [ 8 ].

Figure  5 maps the most cited documents, as the most representative articles in the conceptual structure of sustainable leadership and sustainable entrepreneurship.

Map of the most cited documents

Figure  6 maps the documents contributing most. Absolute contributions measure the weight of each document in the information summarised by the two axes, i.e., in the conceptual structure of sustainable leadership and sustainable entrepreneurship.

Map of the documents contributing most

Figure  7 shows the composition of the clusters formed, classifying them in ascending order of the most cited articles (TC) with the greatest contribution indices (Contrib©) of each article.

The five clusters formed addressing the relation between sustainable leadership and sustainable entrepreneurship are: (1) Heterogeneity of Contexts (2) Conceptual analysis (3) Entrepreneur and leader behaviour; (4) Instruments and motivations, and (5) Coverage of entrepreneurial sustainable leadership.

3.2.1 Cluster 1—Heterogeneity of contexts

This cluster includes 54 studies published between 2010 and 2023 representing a heterogeneity of sustainable leadership and sustainable entrepreneurship focused on contexts of variables that complement the process of interconnecting the topic. The main words highlighted in this cluster are: knowledge-sharing; frugal innovation; competitiveness practices; collectivist cultural values; sustainable entrepreneurial ecosystems; media availability; strategic framework and intellectual structure; SMEs (Small and Medium-Sized Enterprises); social capital and economic growth.

Table 5 shows the most cited articles (TC) and those that contributed the most (Article Contribution) to the cluster. The table also shows the methodology used, the theories applied, the research gaps, the limitations identified and the quality of the journal.

Kuckertz and Wagner [ 57 ] studied the influence of sustainability orientation on entrepreneurial intentions, taking business experience into consideration. They pointed out that business experience can moderate the relation between sustainability orientation and entrepreneurial intentions, influencing the transformation of those intentions into concrete actions. The results show that sustainability orientation has a positive impact on entrepreneurial intentions, especially among students with business experience, i.e., entrepreneurs with greater business experience may be more likely to translate their sustainability orientation in line with socio-environmental and economic principles. This corroborates the idea that attitude towards sustainability and social support have a significant impact on the sustainable entrepreneurial intentions of Serbian students [ 75 ].

Shepherd et al. [ 93 ] address the relation between personal values and assessment of entrepreneurial opportunities that can damage the environment. They observe that personal values can lead to a disconnection between concern about nature and assessment of entrepreneurial opportunities that cause damage. That is, by disengaging personal pro-environmental values cognitively, entrepreneurs (decision-makers) can in some circumstances perceive opportunities that harm the environment as highly attractive and therefore ready to be exploited. This disengagement of values can lead to decisions and behaviour that are not in keeping with environmental sustainability. Nevertheless, the sharing of sustainability-oriented knowledge can promote the development of sustainable entrepreneurial competences [ 72 ].

Ploum et al. [ 85 ] developed a validated framework of competences for sustainable entrepreneurship. The authors discovered six necessary competences for sustainable entrepreneurship: (1) critical, reflective thought, (2) systematic vision, (3) inter-disciplinary collaboration, (4) participation, (5) innovation and (6) leadership. Concerning this last competence, the authors argue that sustainable entrepreneurs need to be effective leaders to create and maintain sustainable and successful businesses. In another study, sustainable leadership of human capital has a positive impact on work results, mediated by knowledge-sharing behaviour [ 54 ].

Pinkse and Groot [ 84 ] studied the relation between sustainable entrepreneurship and corporate political activity in overcoming market barriers in the clean energy sector in Holland. These barriers faced by sustainable entrepreneurs include imperfect information, government intervention, monopoly power and deficient price mechanisms that strengthen the position of the dominant technology and the incumbents’ corresponding interests. They found that active corporate political activity can be an effective strategy to overcome these market barriers, that is, politically active sustainable entrepreneurs. Therefore, well-defined business strategies that incorporate sustainable aspects [ 101 ] and the availability of media [ 112 ] stimulate sustainable entrepreneurship.

Similarly, Park and Chung [ 79 ] explored how political leaders can learn from the past to improve the sustainability of their leadership in a pandemic situation. The authors developed a theoretical framework of policy implementation that combines collaboration between the public and private sectors (Public–Private Partnership or PPP) to cope efficiently with urgent crises such as COVID-19. In the particular case of South Korea, they concluded that rapid, effective management of crisis situations and public–private partnerships were essential in overcoming the pandemic. At the same time, collectivist cultural values moderate the relation with sustainable entrepreneurship [ 60 ] and social capital plays a crucial role in sustainable entrepreneurship during the COVID-19 crisis [ 58 ].

Iqbal and Piwowar-Sulej [ 48 ] explore how sustainable leadership can stimulate sustainable entrepreneurship, through heterogeneous sharing of knowledge in the context of frugal innovation. The authors propose a model for frugal innovation based on sustainable leadership and the sharing of heterogeneous knowledge, considering environmental, social and economic sustainability. The main findings are that sustainable leadership has a significant positive impact on the sharing of internal and external heterogeneous knowledge and that the latter has a mediating role in the relation between sustainable leadership and frugal innovation. Therefore, sustainable leadership promotes the diversified sharing of knowledge, identification of frugal innovation opportunities and the development of creative, sustainable solutions. Furthermore, learning is an important component in the regional context of sustainable entrepreneurship [ 82 ].

Jerónimo Silvestre et al. [ 50 ] state that what stimulates corporate sustainability, i.e., the need to satisfy stakeholders’ expectations, regulatory pressure and the need to manage risks and opportunities related to sustainability, are factors motivating companies to adopt sustainable practices. Dai et al. [ 24 ] add that the influence of corporate social responsibility (CSR), style of leadership and sustainable entrepreneurship have a significant impact on sustainable performance, mediated by organisational commitment. In another study, factors such as innovation, collaboration and sustainability are found to influence sustainable entrepreneurship [ 69 ].

3.2.2 Cluster 2—Conceptual analysis

Studies in this cluster address more methodologically the conceptual analysis of the topic. It includes 13 studies published between 2011 and 2023. The main words in this cluster are: sustainable entrepreneurship, innovation, conceptual structure, case study, connection with the organisation, sustainability challenges, and effective corporate entrepreneurship.

Table 6 shows the most cited articles (TC) and those that contributed the most (Article Contribution) to the cluster. The table also shows the methodology used, the theories applied, the research gaps, the limitations identified and the quality of the journal.

Schaltegger et al. [ 91 ] analysed the co-evolution of sustainable entrepreneurship, innovation and organisational transformation by analysing business models for sustainability. From this perspective of the business model with the theory of sustainable entrepreneurship, the authors analysed the co-evolution of business models for sustainable niche pioneers and conventional mass market players aiming to transform market sustainability. They concluded that business models are important for corporate performance in general and for corporate sustainability in particular. Similarly, the use of technological innovations, such as digital marketing, can help to create awareness about the entrepreneurial ecosystem [ 4 ].

Gray et al. [ 37 ] addressed the promotion of sustainable entrepreneurship in communities threatened by the climate, using a case study in Samoa. They observed how external factors and random events impact on recognition and exploitation of sustainable opportunities in such communities. In this scenario, they found that the main organisational capacities necessary to cope with exogenous shocks are: the capacity to adapt to cope with environmental and economic changes; innovation capacity to create business solutions and opportunities; and the capacity to collaborate, working with other organisations and stakeholders to face complex challenges. Therefore, awareness of adverse consequences and the entrepreneurial attitude influence the process of identifying sustainable opportunities [ 28 ].

Anbarasan and Sushil [ 6 ] studied the importance of stakeholders’ engagement in sustainable companies, presenting a conceptual framework and a case study in the ITC company. They examined what caused that company to remain firm in its sustainable development and one reason was the identification of factors that stimulate ITC’s vision of sustainability, i.e., the customer and the government, together with the triple bottom line (economic, social and environmental aspects). They illustrate how stakeholders’ engagement can stimulate sustainable entrepreneurship and how leadership can involve stakeholders in sustainability initiatives, with environmental conservation programmes, social inclusion and rural development. The resulting mutual benefits for the company and stakeholders include the creation of shared value and a strengthened market position for ITC. In another study, sustainable entrepreneurial orientation has a positive and direct relation with company performance, this being improved when mediated by the creation of functional value for the customer [ 22 ].

Kelley [ 53 ] explores the relation between sustainable corporate entrepreneurship and its evolution in the organisational context. The author describes how companies can develop their entrepreneurial capacity over time, adjusting and improving strategies, organisational structures and decision-making processes. In this scenario, the leader’s performance is essential to ensure inclusion of sustainability principles in these processes. The author stresses the importance of a solid connection between leadership and sustainable entrepreneurship. So, leaders must provide internal entrepreneurs with the necessary support and resources, allowing them to develop their sustainable ideas and projects. The findings reveal that sustainable corporate entrepreneurship requires organisations to create an environment that encourages and supports innovation, and that organisations must develop a culture of collaboration and trust between employees and administration in order to promote the entrepreneurial spirit. Organisations must also invest in resources and technology to let employees look for entrepreneurial initiatives. That is, firms must develop strategic objectives to orient entrepreneurs, a management structure to support their work and processes that inform assessment and decision-making.

Bakry et al. [ 12 ] evaluate the effectiveness of innovation ecosystems in facilitating the adoption of sustainable entrepreneurship. They concluded that the benefits of such ecosystems in promoting sustainable entrepreneurship, besides favouring a climate for the creation and development of new firms, can include collaboration between firms, universities and other organisations to create innovative solutions to social and environmental problems together with the appropriate finance. The authors also point out that innovation ecosystems should allow stakeholders to exploit new entrepreneurial/innovative opportunities and access the resources and capacities necessary to do so. For that, they use the hierarchical decision model (HDM) to build a general ecosystem evaluation framework for entrepreneurship and innovation ecosystem strategies to increase the adoption of innovation in sustainable entrepreneurship. Corroborating this idea, according to Almansour [ 4 ], business training and firms can be more oriented to sustainability, promoting technological innovations. University firm incubators and entrepreneurial training in HEIs can also be more effective when aligned with the relevant sustainable development goals (SDG).

Kim et al. [ 55 ] developed a model of effective corporate entrepreneurship that emphasizes the importance of social responsibility and employees’ well-being. They proposed that a "humanitarian" approach to managing employees is a key antecedent to creating and maintaining an entrepreneurial orientation (EO). They also emphasized that human organisational practices ultimately lead to sustainable entrepreneurship and innovation in companies. The model proposed by the authors, called "Humane Entrepreneurial Framework" (HEF), highlights the importance of corporate social responsibility, ethical governance and environmental risk management as key elements for the success of effective, sustainable corporate entrepreneurship. That is, they suggest that the creation of high-performance work systems improves the human and social capital necessary to develop entrepreneurial orientation, leading to the desired entrepreneurial results. The HEF recognises that leadership is essential to orient corporate entrepreneurship towards sustainable practices, this being a critical factor for the model’s success.

3.2.3 Cluster 3—Entrepreneur and leader behaviour

This cluster contains quantitative and qualitative research on the topic, including 23 studies published between 2012 and 2023. The main words in this cluster are: sustainable entrepreneurship, entrepreneurial behaviour, leadership, sustainability, ecosystem, stakeholder, corporate social responsibility, sustainable development, entrepreneurial intention and sustainable business.

Table 7 shows the most cited articles (TC) and those that contributed the most (Article Contribution) to the cluster. The table also shows the methodology used, the theories applied, the research gaps, the limitations identified and the quality of the journal.

Rodgers [ 87 ] studied sustainable entrepreneurship practices in small and medium-sized enterprises (SMEs), focusing on the relation between corporate social responsibility and environmental management, and providing valuable insights into the strategies real firms adopt to integrate sustainability in their operations and identify sustainable business opportunities. Furthermore, the author states that sustainable entrepreneurs adopt an innovative approach oriented to solutions, seeking ways to reduce the environmental impact, create sustainable products or services and engage with the local community. The conclusion is that SMEs that are concerned about sustainability pursue other objectives besides financial ones and are willing to go to great lengths to achieve them. Monetary measures are not absent, but they are strongly conditioned by the business’s ecological conscience. Other studies reveal a positive relation between entrepreneurial orientation and corporate social responsibility, with dynamic capacity being identified as a mediating factor in that relation [ 102 ] and a positive relation between entrepreneurial cognitions and orientation towards sustainability in business practices [ 1 ].

McSherry et al. [ 66 ] analysed the role of nursing managers, leaders and teachers in promoting excellence in nursing care. The authors describe how these health professionals can improve the image of nursing and create health environments that allow excellence in nursing care. They suggest adopting sustainable practices in care provision, encouraging innovation, providing training and professional development and promoting an organisational culture that values sustainability. Also to create healthcare environments, they propose genuine shared work partnerships and collaboration among nursing managers, leaders and educators and their associated organisations. In this way, sustainability in nursing can be achieved by implementing care practices that minimise the environmental impact and promote social equality.

McSherry et al. [ 66 ] also conclude that nursing leaders, managers and educators play a fundamental role in improving the image of nursing and ensuring the fundamental principles of dignity, respect, sympathy and patient-focused care are central in all aspects of nursing practice. They identify factors and key strategies that contribute to excellence in care, including effective leadership, support for the team, professional development, a culture of safety and patient participation.

Therefore, McSherry et al. [ 66 ] reinforce the importance of adopting a sustainable leadership approach to facilitate and support the front-line team to innovate and change, as nursing has a fundamental role in promoting health and well-being in people and communities. This is imperative to restore image and show that nurses care and are excellent at what they do. Adopting sustainable practices in healthcare, encouraging innovation, providing training and professional development and promoting an organisational culture valorises sustainability and professionals in the area of nursing.

Hanohov and Baldacchino [ 38 ] study the recognition of opportunities in the context of sustainable entrepreneurship, investigating how entrepreneurs identify and assess sustainable business opportunities. The research adopts an exploratory approach to understand the cognitive processes and strategies used by entrepreneurs to identify sustainable opportunities. They find that environmental awareness, identifying unmet needs, creativity in generating sustainable ideas and the capacity to assess the potential of sustainable business are important elements in this process. They also conclude that sustainable entrepreneurs’ knowledge about natural and communal environments, their motivation to create benefits both for themselves and others, as well as their entrepreneurial knowledge, influence the identification of sustainable opportunities. Moreover, the desire to work independently, personality traits and personal circumstances are sources of motivation, while previous work experience and past projects develop entrepreneurial knowledge.

In parallel, sustainable institutional entrepreneurship is influenced by internal and external factors, such as personal values, government regulations, support networks and strategic partnerships [ 33 ]. The factors stimulating sustainable entrepreneurial practices are found at the individual, organisational and institutional level: environmental awareness, regulatory pressures, the search for competitive advantage and adopting sustainable technologies [ 107 ].

Wagner et al. [ 106 ] explore academic programmes related to sustainable entrepreneurship and their impact on regional development, in a comparative study based on three cases in Germany. The results provide a more detailed vision of universities’ different roles, how knowledge spillovers are created and the opportunities, results and effects produced at the regional and global levels. The study demonstrates that, depending on the regional context, universities’ different configurations, paths and points of intervention can also improve sustainable business ecosystems. They underline that academic programmes related to sustainable entrepreneurship can also serve as research and innovation centres, promoting collaboration among students, lecturers and other stakeholders. That collaboration can result in developing innovative and sustainable solutions for the problems faced by local communities. Furthermore, programmes can act as facilitators of knowledge and technology transfer between academia and firms, supporting the growth of sustainable undertakings in the region and consequently regional development.

Suriyankietkaew [ 98 ] examines the effects of key determinants of leadership on business sustainability in entrepreneurial companies. The aim was to determine what business leaders can do to increase financial performance in the long term and improve stakeholder satisfaction, in this way contributing to long-term business sustainability. The author finds seven valid and reliable factors of leadership that were discovered as new, underlying constructs of leadership to examine business sustainability in small entrepreneurial firms in Thailand. These factors are trust, the team’s innovative orientation, a strong, shared vision, ethical and moral leadership, transformational leadership, authentic leadership and servant leadership. The results reveal three significantly positive factors or stimulants (trust, the team’s innovative orientation and a strong, shared vision) to improve two results of sustainability performance (financial performance and stakeholder satisfaction). Therefore, certain key determinants of leadership, such as a strategic vision, orientation towards sustainability and management skills, have a significant impact on business sustainability in entrepreneurial firms.

Arslan et al. [ 9 ] go deeper into the development of sustainable entrepreneurship in Oman through a qualitative approach with multiple stakeholders. They find that the nascent business ecosystem, bureaucracy and the lack of human capital (attraction and retention) seem to be significant challenges for business-people. They show that the lack of specific training programmes for the context and hesitation based on culture prevent following up sustainable entrepreneurship possibilities in Oman. The main findings are the importance of factors such as environmental awareness, collaboration among stakeholders and government support, which are fundamental for the development of sustainable entrepreneurship in that country. In another study, perception of the strength of sustainable entrepreneurial ecosystems in the dimensions of stakeholder theory and culture is important to promote sustainable entrepreneur [ 15 ].

Waris et al. [ 108 ] discuss entrepreneurial intention moved by sustainability among university students in Pakistan. The study reveals that university entrepreneurial support has a strong influence on attitude towards sustainable entrepreneurship and entrepreneurial self-efficacy. That is, positive environmental attitudes, knowledge about sustainability and entrepreneurship education have a positive influence on entrepreneurial intention stimulated by sustainability among these students. In fact, programmes of sustainable entrepreneurial orientation have a positive impact on students’ awareness and skills in relation to sustainable entrepreneurship [ 26 ].

3.2.4 Cluster 4—Instruments and motivations

Most studies in this cluster are qualitative and of conceptual analysis, followed by quantitative studies on the topic, in a total of 45 studies published between 2007 and 2023. The words standing out here are: sustainable entrepreneurship, environmental sustainability, innovation, entrepreneurial action, market imperfections, recognition of opportunity, convergent process model, perceived barriers, risks, ethics, value creation, entrepreneurial ecosystems, social solidarity economy, leadership, sustainable leadership, recognition and exploitation of opportunities, and sustainable entrepreneurship tactics.

Table 8 shows the most cited articles (TC) and those that contributed the most (Article Contribution) to the cluster. The table also shows the methodology used, the theories applied, the research gaps, the limitations identified and the quality of the journal.

Schaltegger and Wagner [ 92 ] analysed the categories and interactions between sustainable entrepreneurship and innovation in sustainability, proposing a framework for that relation. The framework was based on a typology of sustainable entrepreneurship, including social and institutional entrepreneurship and relating them to innovation in sustainability. Here, innovation in sustainability involves the development and implementation of new practices, products, processes and business models that aim to reduce the environmental impact, improve resource efficiency and satisfy consumers’ demands for more sustainable products and services. The findings suggest that the degree of orientation towards environmental or social responsibility in the firm is assessed based on environmental and social goals and policies, on the organisation of environmental and social management and communication of environmental and social questions. Moreover, the firm’s impact on the market is measured based on market quota, sales growth and competitors’ reactions. The authors also state that the managers of the main companies have been central in stimulating sustainable development with their innovations, that sustainable entrepreneurs and sustainability managers are shaping markets and society considerably. In this way, categories and interactions provide insights into how sustainable leadership and sustainable entrepreneurship can be applied in different contexts and sectors.

Dean and McMullen [ 25 ] develop a theory of sustainable entrepreneurship, proposing entrepreneurial actions to reduce the environmental degradation of global socio-economic systems. Through such actions, sustainable entrepreneurs seek to develop and implement solutions that minimize the environmental impact, including efficient use of resources, adopting clean technology and promoting sustainable production and consumption practices. Those actions contribute to preserving the environment and long-term sustainability. In this way, the theory highlights the importance of entrepreneurial motivation, the capacity to identify sustainable opportunities, obtaining resources and institutional support in promoting sustainable entrepreneurship. Briefly, these authors argue that relevant market failings concerning the environment represent opportunities to achieve profitability, while reducing economic behaviour that harms the environment.

Cohen and Winn [ 19 ] aimed to develop the argument that four types of market imperfection (inefficient firms, externalities, price mechanisms, information shortcomings and asymmetries) contribute to environmental damage and also provide significant opportunities to create radical technology and innovative business models. The authors underline that the sustainable entrepreneurship approach can be a competitive differential for entrepreneurs, letting them create an advantage in imperfect markets. They show these opportunities establish the basis for an emerging model of sustainable entrepreneurship, allowing founders to obtain entrepreneurial income while simultaneously improving local and global social and environmental conditions. Therefore, sustainable entrepreneurship emerges as a response to market failings and seeks to fill gaps in the supply of sustainable products and services. By providing sustainable products and services, sustainable entrepreneurs satisfy consumers’ growing demands for more responsible solutions, which can result in greater customer loyalty, brand-building and a competitive advantage in a business environment increasingly aware of sustainability.

Hockerts and Wüstenhagen [ 43 ] discuss the role of incumbents and new entrants in sustainable entrepreneurship. They highlight the distinction between incumbents, established firms that dominate in their industries, and new entrants, entrepreneurs entering existing markets with innovative proposals. The authors state that in the initial stages of an industry’s transformation to sustainability, new entrants are more likely than incumbents to seek opportunities related to sustainability. This is because new entrants have the advantage of being more flexible and open to sustainable innovations. Meanwhile, incumbents react to those new entrants’ activities by engaging in corporate sustainable entrepreneurship. This is due to incumbents having the advantage of resources, experience and influence in the market. In that relation, the authors discuss the importance of incumbents’ leadership to stimulate the transition to more sustainable practices and new entrants’ sustainable entrepreneurship in introducing more sustainable business models, developing ecologically correct products and services, and challenging established market practices. They stress that collaboration between incumbents and new entrants can encourage the change towards more sustainable practices. Incumbents can learn from the innovation brought by new entrants and incorporate more sustainable approaches in their operations. On the other hand, new entrants can benefit from incumbents’ experience and resources to scale up their sustainable initiatives.

Hoogendoorn et al. [ 44 ] studied the role of perceived barriers and risk in sustainable entrepreneurship, as faced by sustainable entrepreneurs in establishing their business due to the discrepancy between the creation and appropriation of private value and social value. According to the authors, barriers can include regulatory restrictions, lack of access to financial resources, lack of awareness of sustainable practices and resistance to change inside the organisation, all hindering sustainable entrepreneurs’ adoption of sustainable practices. Sustainable entrepreneurs perceive more institutional barriers than regular entrepreneurs when setting up a business. Concerning the perceived risks associated with sustainable entrepreneurship, no significant differences were found between sustainable and regular entrepreneurs in terms of attitudes to risk or perceived financial risks. Summarising, the authors conclude that sustainable entrepreneurs feel more disadvantaged by the perceived barriers, such as the institutional environment, and have a different attitude and perception of risk from regular entrepreneurs. In addition, sustainable entrepreneurs perceive more institutional barriers regarding the lack of financial and administrative support, and information when starting the business, and so are more likely to fear personal failure than regular entrepreneurs.

Long et al. [ 62 ] explored how to introduce responsible innovation in new firms developing innovations in agriculture, food or energy, being oriented towards sustainability. The study presented a specific tool to help new companies in the process of developing responsible innovation. That tool aims to give practical guidelines so that entrepreneurs can incorporate ethical, social and environmental considerations from the initial stages of setting up the business. In addition, how to incorporate the benefits of responsible innovation for sustainable entrepreneurship when new firms adopt responsible innovation practices to gain competitive advantages, such as greater acceptance in the market, a positive reputation among stakeholders and access to financing opportunities and strategic partnerships.

Andersén et al. [ 7 ] studied whether CEOs with an environmental orientation and environmentally friendly suppliers can stimulate small firm growth. They examined the relation between green purchasing capacities, the CEO’s environmental orientation and company growth. The results of 304 small Swedish manufacturing companies indicate a significant relation between green purchasing capacities (GPCs) and firm growth, that relation being moderated positively by the CEO’s environmental orientation. The authors found that supply partners sharing the same sustainable vision can provide resources and products/services aligned with the principles of sustainability, which can stimulate small firms’ growth. They also point out the importance of small companies for sustainable environmental development and how they can contribute to environmental sustainability through green purchasing practices.

3.2.5 Cluster 5—Coverage of sustainable entrepreneurial leadership

This cluster is formed mainly of quantitative (10) followed by qualitative studies (2) and literature reviews (2) on the subject, totalling 14 studies published between 2017 and 2023.

The main words in this cluster are: sustainable entrepreneurship, transformational leadership, sustainable leadership, sustainable performance, innovation, sustainable development, technological and market turbulence, pro-active sustainability strategy, environmental performance, creative self-efficacy, sustainable entrepreneurial competence, entrepreneurial intentions, orientation to the sustainable market.

Table 9 shows the most cited articles (TC) and those that contributed the most (Article Contribution) to the cluster. The table also shows the methodology used, the theories applied, the research gaps, the limitations identified and the quality of the journal.

Vuorio et al. [ 104 ] studied the stimulants of entrepreneurial intentions in sustainable entrepreneurship, i.e., the reasons for people wanting to become entrepreneurs. The authors conclude that attitudes to sustainability and the perceived attractiveness of entrepreneurship increase entrepreneurial intentions oriented to sustainability. Moreover, attitudes to sustainability are positively impacted by altruism, while the perceived attractiveness of entrepreneurship is stimulated by the intrinsic and extrinsic rewards. From another perspective, the sustainability intention mediates the relation between behavioural control of sustainability and sustainable entrepreneurship [ 56 ] and there is a positive relation between competence in sustainable entrepreneurship and entrepreneurial intentions, in the educational context [ 52 ].

Carayannis et al. [ 17 ] explored the role of organisational artefacts and the impacts of routines on organisational change, policies, structure and performance, in the search for sustainable excellence. The authors conclude that organisational routines and artefacts play an important role in enabling and sustaining organisational intelligence, which is essential for corporate excellence and resilience. In that process, the acquisition of knowledge and learning competences shape and improve a company’s organisational intelligence, leading to robust competitiveness and sustainable entrepreneurship.

Burawat [ 16 ] examined the relations between transformational leadership, sustainable leadership, lean manufacturing processes and sustainable performance in industrial SMEs in Thailand. The author concluded that lean manufacturing has a partial mediating effect on the relation between transformational leadership and sustainable performance and between sustainable leadership and sustainable performance. In addition, the structural model is different in automobile and non-automobile companies, and different between firms that implement the lean programme for less than five years and over five years. Companies pay more attention to customer involvement with some attention to employee and supplier involvement. Managers give advice and exchange ideas with their followers instead of inspiring and giving opportunities to make decisions. For that reason, the article recommends that before initiating lean manufacturing practices, company managers should internalize the concept and the process of these practices. Only in this way will they have better results in operational, economic and sustainable performance.

Iqbal et al. [ 46 ] analysed the relation between sustainable leadership and sustainable performance in SMEs in China and India, proposing a model of innovation based on frugality for sustainable development in a context of technological and market turbulence. The findings allow the conclusion that frugal innovation has a mediating role in emerging markets and that technological and market turbulence has a significant moderating effect on the sustainable leadership-frugal innovation relation. However, the effect of sustainable leadership on frugal innovation did not vary for the different values of business bricolage. Therefore, the authors conclude that technological and market turbulence increases the impact of sustainable leadership practices on frugal innovation, this being an effective approach to promote sustainable development in turbulent environments.

From another angle, Iqbal et al. [ 47 ] study sustainable leadership, frugal innovation and environmental performance based on upper echelons theory. This theory of leadership states that organisational leaders’ cognitive and ideological characteristics influence organisational results through strategic choices. The authors discovered that frugal innovation partially and positively mediates the effect of sustainable leadership on environmental performance.

Javed et al. [ 49 ] studied the relation between sustainable leadership and employees’ innovative behaviour, focusing on the mediating role of creative self-efficacy. They found that the effect of sustainable leadership on creativity in the workplace is essential, revealing that creative self-efficacy mediates the relation between sustainable leadership and employees’ innovative behaviour.

Awan and Khan [ 11 ] examined the moderating role of sustainable leadership in purchaser-supplier relations and in supply chain performance. They found that sustainable leadership mediated positively the relation between the purchaser-supplier relation and supply chain performance. They indicated that four aspects of sustainable leadership (going beyond one’s own interests, speaking enthusiastically, a focus on training and teaching and seeing new ideas about sustainability matters) improve individually the firm’s social performance. Therefore, relations between companies are contingent and cannot be generalised, and managers must continuously explore the best approaches to improve sustainability performance.

Han and Niu [ 37 ] studied the relation between sustainable entrepreneurship orientation, sustainable market orientation and radical innovation of green products for sustainable performance (environmental, social and economic) in Chinese sport goods manufacturers. The findings suggest that such organisations should revise their organisational strategies, incorporating the elements of sustainability in their objectives. Moreover, sustainable entrepreneurship orientation and sustainable market orientation are associated positively with radical innovation of green products and sustainable performance. Consequently, innovation in green, radical products increases the elements of sustainable development, i.e., it increases the capacity to reduce the environmental impact, contribute to social well-being and generate profit and economic growth. In other words, innovation in green processes mediates the relation between green entrepreneurial orientation, pro-active sustainability strategy and environmental performance [ 31 ].

4 Framework

The framework is a conceptual map, a tool helping to identify additional search terms in searching the literature; clarifying thought on the structure of the literature review in preparing to write the review; and understanding theories, concepts and relations among them [ 88 ]. Each framework bears the particularity of each researcher’s understanding of the subject, and can be modified as the search advances, serving as references for systematic reviews [ 88 ]. The framework used in this study (Fig.  8 ) is an adaptation of those used by Marasco [ 65 ], Pokharel and Mutha [ 86 ] regarding the naming and classification of groups of analysis.

Considering the research question here: what is the connection between sustainable leadership and sustainable entrepreneurship, Fig.  8 presents the framework and the main findings of the clusters relating the effectiveness of that association. The connection between sustainable leadership and sustainable entrepreneurship can be considered a partnership of positive results.

Considering the clusters, sustainable leadership can play an essential role in promoting sustainable entrepreneurship in various contexts: frugal innovation [ 45 , 46 , 48 ]; innovation [ 62 ]; sustainable competitiveness practices in SMEs [ 34 ]; international culture [ 60 ], agricultural start-ups [ 3 ]; media availability [ 112 ]; institutional co-evolution [ 109 ]; performance in clean technology companies [ 74 ]; communities threatened by climate [ 35 ]; stakeholder engagement [ 6 , 83 ]; innovation ecosystems [ 12 ]; promoting excellence in nursing care [ 66 ]; identifying opportunities [ 38 ]; regional development [ 106 ]; exploiting opportunities in imperfect markets [ 19 ]; creative self-efficacy [ 49 ].

Furthermore, sustainable leadership has a fundamental role in stimulating corporate entrepreneurship, promoting environmental orientation, in business incubators and other business sectors. The association between sustainable entrepreneurship and sustainable leaders creates an environment that favours the adoption of sustainable business practices considering economic, environmental and social aspects. This promotes a sustainable organisational culture of training and collaboration among employees, involving and engaging stakeholders in the decision-making process and implementation of those sustainable practices.

Therefore, sustainable leadership can provide strategic orientation, support and collaboration for local entrepreneurs, helping them to face climate challenges and develop businesses that are socially and environmentally responsible, thereby contributing to communities’ resilience and sustainability. This stimulates an organisational culture that promotes creativity and innovation, encouraging employees to identify and exploit sustainable business opportunities. In this way, innovation ecosystems provide a platform where entrepreneurs, leaders and other actors can interact, collaborate and promote sustainable entrepreneurship through internalization of that concept. This makes it possible to achieve effective and sustainable corporate entrepreneurship.

From another angle, sustainable leadership can enable nursing professionals to engage in sustainable entrepreneurship, aiming to achieve better results for patients, the nursing team, the health organisation and the environment. Here, sustainable leaders play a fundamental role by giving direction and support to entrepreneurs in the quest for sustainable opportunities. That contributes to creating businesses that not only generate profit but also have a positive impact on society and the environment. In synthesis, the link between sustainable leadership and sustainable entrepreneurship is essential to stimulate the development of innovative, sustainable solutions that create value for both the organisation and society as a whole.

Table 10 presents the suggestions from studies based on each cluster found in this research.

5 Conclusion, implications and limitations

The article studies the relation between sustainable leadership and sustainable entrepreneurship through a systematic review of the scientific literature. From the Web of Science database, using inclusion/exclusion criteria, 149 articles were retrieved and analysed, performing a bibliometric analysis using R-Studio software.

From the results obtained, sustainable leadership and sustainable entrepreneurship are two inter-connected concepts with a fundamental role in promoting responsible business practices and seeking solutions to current socio-environmental challenges. The studies show that sustainable leadership has an important role in creating an environment favouring sustainable entrepreneurship, by promoting sustainable values and practices in organisations, since leaders can be agents of change, inspiring and motivating entrepreneurs to follow a sustainable business path [ 25 , 29 , 30 , 48 , 49 , 52 , 67 , 68 , 76 , 80 , 85 , 95 , 97 , 111 ].

Sustainable entrepreneurial leadership plays an important role in the sustainable growth of companies, integrating responsible environmental and social practices into all activities, promoting innovation and efficiency through the adoption of green technologies and environmentally conscious management practices. Sustainable entrepreneurial leadership makes it possible to create an organisational culture that values social and environmental responsibility, actively engaging all stakeholders, such as customers, suppliers, local communities and investors. By ensuring that sustainable business practices are recognised and valued, the sustainable entrepreneurial leader promotes sustainable, balanced and lasting growth.

By focusing on the connection between sustainable leadership and sustainable entrepreneurship, it is stated that these two constructs are connected with the following Sustainable Development Goals (SDGs) Footnote 1 :

a) Sustainable leadership:

SDG5: Achieve gender equality and empower all women and girls.

Target: 5.1 End all forms of discrimination against all women and girls everywhere.

Indicator(s): 5.1.1 Whether or not legal frameworks are in place to promote, enforce and monitor equality and non‑discrimination on the basis of sex.

SDG 8: Decent work and economic growth, targeted to the promotion of sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all, by developing a responsible exercise of leadership.

Target: 8.3 Promote development-oriented policies that support productive activities, decent job creation, entrepreneurship, creativity and innovation, and encourage the formalization and growth of micro-, small- and medium-sized enterprises, including through access to financial services.

Indicator(s): 8.3.1 Proportion of informal employment in total employment, by sector and sex.

b) Sustainable entrepreneurship:

SDG9: Build resilient infrastructure, by promoting inclusive and sustainable industrialization and fostering innovation.

Target: 9.2 Promote inclusive and sustainable industrialization and, by 2030, significantly raise industry’s share of employment and gross domestic product, in line with national circumstances, and double its share in least developed countries.

Indicator(s): 9.2.1 Manufacturing value added as a proportion of GDP and per capita/9.2.2 Manufacturing employment as a proportion of total employment.

SDG10 Reduce inequality within and among countries.

Target: 10.2 By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.

Indicator(s): 10.2.1 Proportion of people living below 50 per cent of median income, by sex, age and persons with disabilities.

SDG12: Ensure sustainable consumption and production patterns.

Target: 12.2 By 2030, achieve the sustainable management and efficient use of natural resources.

Indicator(s): 12.2.1 Material footprint, material footprint per capita, and material footprint per GDP/12.2.2 Domestic material consumption, domestic material consumption per capita, and domestic material consumption per GDP.

The analysis reveals that the majority of research focuses predominantly on sustainable entrepreneurship in detriment of sustainable leadership. Thus, it is recommended that further research be conducted into sustainable leadership, with particular emphasis on its effectiveness in promoting sustainable entrepreneurship. This approach aims to fill one of the gaps identified in the existing literature.

6 Theoretical and practical implications, and limitations

The results obtained give rise to some implications. From a theoretical point of view, this study reveals the existence of an intrinsic connection between sustainable leadership and sustainable entrepreneurship. The principles underlying sustainable leadership tend to foster entrepreneurship and positively influence entrepreneurial attitudes towards sustainability, thus promoting sustainable development.

From a practical perspective, the interrelationship between sustainable leadership and sustainable entrepreneurship shows how the former tends to promote, inspire and support entrepreneurs in adopting sustainable practices. This dynamic not only generates a positive socio-environmental impact, but also contributes to the creation of economic value for the company. Sustainable leadership involves integrating environmental and social objectives into the economic logic of the business, creating value for both the company and society. In addition, sustainable leadership encompasses entrepreneurial actions that overcome barriers to the efficient functioning of environmental resource markets, promoting economic and ecological sustainability.

The study has several limitations. One lies in the use of a single database, Web of Science, as others could be included, to increase understanding of the subject.

See Table  11

Data availability

No datasets were generated or analysed during the current study.

For further details about the SDGs, targets and indicators please consult:

https://sdgs.un.org/goals

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The authors acknowledge the highly valuable comments and suggestions provided by the editors and reviewers, which contributed to improving the clarity, focus, contribution, and scientific soundness of the current study.

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Ribeiro, G.K.A., Leitão, J. Sustainable leadership and sustainable entrepreneurship: a systematic literature review. Discov Sustain 5 , 188 (2024). https://doi.org/10.1007/s43621-024-00383-3

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Leadership for AI Transformation in Health Care Organization: Scoping Review

Authors of this article:

• Abi Sriharan 1, 2 , MSc, DPhil   ; 
• Nigar Sekercioglu 2 , PhD   ; 
• Cheryl Mitchell 3 , PhD   ; 
• Senthujan Senkaiahliyan 2 , MHSc   ; 
• Attila Hertelendy 4 , PhD   ; 
• Tracy Porter 5 , PhD   ; 
• Jane Banaszak-Holl 6 , PhD  

1 Krembil Centre for Health Management and Leadership, Schulich School of Business, York University, Toronto, ON, Canada

2 Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

3 Gustavson School of Business, University of Victoria, Victoria, ON, Canada

4 College of Business, Florida International University, Florida, FL, United States

5 Department of Management, Cleveland State University, Cleveland, OH, United States

6 Department of Health Services Administration, School of Health Professions, University of Alabama Birmingham, Birmingham, OH, United States

Corresponding Author:

Abi Sriharan, MSc, DPhil

Krembil Centre for Health Management and Leadership

Schulich School of Business

York University

MB Room G315

4700 Keele St

Toronto, ON, M3J 1P3

Phone: 1 3658855898

Email: [email protected]

Background: The leaders of health care organizations are grappling with rising expenses and surging demands for health services. In response, they are increasingly embracing artificial intelligence (AI) technologies to improve patient care delivery, alleviate operational burdens, and efficiently improve health care safety and quality.

Objective: In this paper, we map the current literature and synthesize insights on the role of leadership in driving AI transformation within health care organizations.

Methods: We conducted a comprehensive search across several databases, including MEDLINE (via Ovid), PsycINFO (via Ovid), CINAHL (via EBSCO), Business Source Premier (via EBSCO), and Canadian Business & Current Affairs (via ProQuest), spanning articles published from 2015 to June 2023 discussing AI transformation within the health care sector. Specifically, we focused on empirical studies with a particular emphasis on leadership. We used an inductive, thematic analysis approach to qualitatively map the evidence. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines.

Results: A comprehensive review of 2813 unique abstracts led to the retrieval of 97 full-text articles, with 22 included for detailed assessment. Our literature mapping reveals that successful AI integration within healthcare organizations requires leadership engagement across technological, strategic, operational, and organizational domains. Leaders must demonstrate a blend of technical expertise, adaptive strategies, and strong interpersonal skills to navigate the dynamic healthcare landscape shaped by complex regulatory, technological, and organizational factors.

Conclusions: In conclusion, leading AI transformation in healthcare requires a multidimensional approach, with leadership across technological, strategic, operational, and organizational domains. Organizations should implement a comprehensive leadership development strategy, including targeted training and cross-functional collaboration, to equip leaders with the skills needed for AI integration. Additionally, when upskilling or recruiting AI talent, priority should be given to individuals with a strong mix of technical expertise, adaptive capacity, and interpersonal acumen, enabling them to navigate the unique complexities of the healthcare environment.

Introduction

Artificial intelligence in health care: overview.

Artificial intelligence (AI) technologies have gained significant momentum in health care, presenting a transformative potential across clinical processes, operational efficiency, decision-making, and workforce optimization [ 1 - 3 ]. The global AI market is projected to shift from US $14.6 billion in 2023 to a formidable estimate of US $102.7 billion by 2028 [ 4 ], unveiling a dynamic transformation of unprecedented scale. This investment, coupled with the engagement of nontraditional health care players such as Microsoft, Google, and Amazon and the convergence of technological prowess and health care innovation signaled by generative AI, will place the trajectory of AI in health care in a state of exponential growth [ 5 ].

Current investments in health care AI predominantly center on bolstering data capacity, enhancing computational power, and advancing methodological innovations in AI. This includes developing and testing AI models and algorithms tailored for precision medicine, drug discovery, clinical decision-making support, public health surveillance, operational optimization, and process improvement [ 6 , 7 ]. Notably, between August 2022 and July 2023, there were over 150 submissions of drug and biological applications incorporating AI and machine learning components to the US Food and Drug Administration, encompassing a wide array of therapeutic domains and developmental stages [ 8 ].

Yet the seamless integration of AI technologies into health care organizational settings presents a multifaceted challenge for health care leaders. This challenge arises from several factors, including the complex nature of AI models, the rapid pace of technological advancement, the imperative of regulatory adherence, ethical concerns surrounding data security and privacy, the risk of perpetuating racial and ethnic biases in data, the necessity of prioritizing human-centric approaches to patient care, and the intricate clinical workflows that must be navigated [ 9 - 15 ]. Furthermore, health care leaders are facing critical and intricate strategic decisions. They must discern which AI solutions merit investment while weighing the merits of in-house development against strategic partnerships with external vendors. Selecting the right vendors and defining the scope of collaboration is pivotal, as is devising a sustainable funding strategy to support both initial development and continuous innovation. Furthermore, they must confront the crucial question of whether to bring in new AI talent or bolster the expertise of their current workforce through upskilling. Each of these decisions will shape the trajectory of health care organizations as they navigate this transformative era. A report by Bain in 2023 revealed that although 75% of surveyed health system executives recognize AI’s potential to reshape the health care industry, only 6% have established concrete strategies related to AI [ 16 ].

The lack of strategy and strategic failures in AI integration not only have financial consequences for organizations but also erode trust among patients, providers, and organizations [ 17 ]. A prominent example is the collaboration between MD Anderson and IBM Watson, aimed at leveraging IBM Watson’s cognitive capabilities to combat cancer. This ambitious endeavor, however, incurred a substantial financial toll of over US $62 million for MD Anderson because of setbacks in clinical implementation [ 18 ].

Despite a growing body of AI literature, including toolkits such as Canada Health Infoway’s “Toolkit for AI Implementers” [ 19 ] and guidance from the US Department of Health and Human Services’ AI Task Force [ 20 ] and the UK National Strategy for AI in Health and Social Care [ 21 ], there is still insufficient scholarly attention on how leadership behavior guides AI transformation in health care. Existing reviews focus on AI in medical education [ 22 , 23 ], workforce impact [ 24 ], applications in clinical medicine [ 13 , 25 ], barriers to implementation [ 26 , 27 ], and ethical considerations [ 28 , 29 ]. However, no systematic mapping of empirical literature has clarified our understanding of leadership or identified gaps in research. Understanding leadership behavior is crucial for health care organizations considering AI because effective leadership shapes the strategic direction, adoption, and successful implementation of AI technologies.

Research Aim

To address this research gap and to establish a future research agenda this scoping review study aims to address two primary questions: (1) What role does leadership play in AI transformation within health care? and (2) What approaches can health care organizations use to empower their leaders in facilitating AI transformation?

Research Approach

This review follows scoping review methodology [ 30 ] to identify and analyze the current literature and report results following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews; Multimedia Appendix 1 ) guidelines [ 31 ].

Key Definitions

In the context of this study, AI refers to combination of machine learning algorithms, large language models, robotics, and natural language processing systems designed to mimic human cognitive functions, enabling machines to perform tasks autonomously or with minimal human intervention.

AI transformation refers to the systematic changes in clinical, operational, or organizational processes and business models due to the introduction of AI systems to optimize decision-making, automate tasks, improve patient outcomes, and drive organizational change. This involves identifying opportunities for AI-related innovation, integrating them into processes, and developing strategies to operationalize implementation while ensuring organizational readiness. This is essential for getting health care organizations AI-ready.

Further, in the context of this study, drawing from seminal management and leadership theories, we view leadership as an effective management practice [ 32 ]. However, we recognize that leadership roles in health care occur at the clinical, organizational, and systems levels of health systems. At the clinical level, leadership emerges through health care professionals who steer patient care and treatment decisions. At the organizational level, leadership involves middle managers such as unit heads and division leaders guiding health care institutions, administrative units, and personnel toward their goals. At the systems level, leadership encapsulates C-suite leadership responsible for navigating regulatory complexities and organizational and structural silos within complex health systems.

Eligibility Criteria

The following inclusion and exclusion criteria guided our study: (1) focused on AI in health care, (2) contained an evaluation of leadership, (3) were written in English, (4) were published in a peer-reviewed journal, (5) published between January 2015 and June 2023, and (6) used research.

Information Sources and Search Strategy

We adopted comprehensive search strategies for the following electronic databases focused on the health care and business literature: MEDLINE (via Ovid), PsycINFO (via Ovid), CINAHL (via EBSCO), Business Source Premier (via EBSCO), and Canadian Business & Current Affairs (via ProQuest). An academic librarian developed these search strategies with input from the research team. We initially conducted the search in Ovid MEDLINE. We then reviewed our search results using the Peer Review of Electronic Search Strategies tool [ 33 ], a checklist for comparing, among other things, the types of errors found in articles and the relative fit of articles to the research question before translating the search strategy into other databases using their command language. Our search was limited to articles published from January 2015 (from the first use of AI-powered chatbots in health care [ 34 ] to June 2023. We then ran searches in 4 databases and exported the final search results into the EndNote reference management software (Clarivate), and we removed duplicate articles manually. To capture any papers that may have been missed during the search process, we did forward and reverse citation searches of systematic review articles related to AI [ 35 ]. However, we did not find any additional articles that met our criteria. Finally, we imported search results to Covidence (Veritas Health Innovation), a review management software for abstract and title screening, full-text screening, and data charting.

Selection of Sources of Evidence and Data Charting

To minimize selection bias, 2 independent screeners reviewed the titles and abstracts of articles identified via the search against the eligibility criteria using Covidence. We identified articles that met the eligibility criteria for a comprehensive full-text screening. Two independent reviewers then evaluated the full texts against the eligibility criteria using Covidence. In discrepancies between the reviewers, a third reviewer served as the consensus reviewer and used Covidence to resolve conflicts between reviewer 1 and reviewer 2. Following the exclusion of irrelevant articles, we used a predefined data extraction form aligned with our research objectives and guiding questions for systematic data collection. Data extraction categories included data on study characteristics (eg, citations and country); methods (eg, aim, data collection methods, and methodological quality); study context (eg, leadership role, ie, clinical, organizational, or systems); leadership practices (ie, behavior, enablers, and barriers to leadership success); results (ie, main results and author conclusion); and an open-ended reviewer note (ie, capture any relevant information that might aid in the data analysis stage). The data abstraction form was piloted on a random sample of 4 included articles and modified based on feedback from the team. Full data abstraction began only after sufficient agreement had been obtained. Two reviewers independently extracted the data using Covidence, and a third reviewer assessed the data extraction for quality and consensus. Three authors then held a group discussion to resolve any conflicts.

Risk of Bias Assessment

The focus of scoping reviews is to provide a comprehensive overview of the available literature, identifying the extent, range, and nature of research on a particular topic rather than assessing the methodological quality of individual studies [ 35 ]. Therefore, we did not perform risk of bias evaluations on the articles included in compliance with the guidelines for scoping reviews.

Data Analysis and Synthesis

Our data analysis was guided by a thematic analysis process [ 36 ]. To ensure the accuracy of the emerging themes, we conducted our analysis collaboratively in reviewer pairs [ 35 ].

We initially analyzed the extracted data using an open-coding method guided by our research questions. Subsequently, we grouped the codes into categories based on the emerging patterns in the data, which we then synthesized into leadership functional domains, capacities, and context.

In the context of our analysis, functional domains refer to distinct areas of responsibility that a leader must effectively manage a task or a role. Capacity, on the other hand, pertains to the abilities—skills, competencies, or behaviors—that a leader must demonstrate to achieve desired goals. Context refers to the environment, conditions, and situational factors that shape and influence leadership practices and decisions.

Study Selection

As described in Figure 1 , the original searches generated 3541 articles published from January 2015 to June 2023. After removing 728 duplicate articles in EndNote, 2813 unique articles were uploaded to Covidence. A total of 2813 relevant studies were then screened using Covidence using the articles’ titles and abstracts. We determined that 97 articles met the criteria for a full-text review for eligibility screening. Within these 97 articles, 75 were excluded as they were opinion articles or commentaries without objective data. After conducting the full-text screening, we found that 22 articles met the final inclusion criteria.

Study Characteristics

Of the 22 studies identified for final inclusion in our review, 12 involved qualitative methods [ 37 - 48 ] such as interviews and case studies, whereas 4 studies involved mixed methods research [ 49 - 52 ] with a qualitative and quantitative strand. There were 3 narrative reports [ 53 - 55 ] based on document synthesis, and 3 studies involved quantitative methods [ 56 - 58 ] such as surveys. These articles focused on clinical, organizational, and systems leadership and came from Canada, China, Finland, Saudi Arabia, Sweden, the Netherlands, the United Kingdom, and the United States. The included papers addressed a broad array of AI applications in health care, including studies focused on improving workflows, quality of care, patient safety, resource optimization, and patient experience. From a clinical domain, researchers focused on primary care, health care systems, radiology, or global health. From a population perspective, the papers covered leadership from the perspective of primary care physicians, radiologists, nurses, nurse managers, public health professionals, global health professionals, health care entrepreneurs, and health care leaders. Table 1 provides a summary of study characteristics.

a N/A: not applicable.

Leadership Tasks Essential for AI Transformation in Health Care

We mapped the themes from the included studies across 4 functional domains of leadership task responsibility—technological (AI innovation), strategic (vision and alignment), operational (process and oversight), and organizational (culture and work environment).

The technological functional domain garnered the most significant attention in the literature. The core themes that emerged under the technological domain primarily focused on applying subject matter expertise and AI technical skills to effectively identify AI opportunities, as well as to foster an innovation mindset to develop, tailor, and seamlessly implement AI-driven solutions to address key AI opportunities within health care organizations.

Within the strategic functional domain, the literature underscored the importance of change management and communication as strategic tools for consensus and collaboration related to the AI transformation process. Another core theme that emerged focused on the critical importance of integrating AI solutions into the existing clinical care processes. This strategic alignment is essential for getting support from the staff and ensuring smooth operations of patient care outcomes while embracing the potential of AI solutions. Although the significance of talent strategy related to the recruitment and retention of AI technical expertise within organizations was mentioned, it was not widely seen across the included papers.

Table 2 provides a summary of how the technological and strategic functional domains map across the papers and provides key themes that emerged with the domain area.

Emerging evidence in the operational functional domain highlights leaders’ need to navigate ethical and risk management issues by establishing robust governance structures prioritizing patient data privacy and security while ethically integrating AI technologies within existing workflows. Additionally, the literature emphasizes that implementing AI in health care will require leaders to ensure new AI solutions comply with existing regulatory and control systems. The literature highlighted that leaders need to pay attention to process agility through continuous monitoring to ensure AI solutions can adapt to contextual changes.

Finally, the organizational functional domain emerges from the thematic analysis as a pivotal area for AI leadership. The literature emphasizes the importance of stakeholder engagement in building collaboration. Furthermore, it underscores the importance of decision makers’ sense-making to enhance their trust in AI opportunities and ensure that AI integration is supported by individuals across the organization. Further, the literature underscored the importance of organizational culture readiness to support physicians and nurses through protected time and incentive pay to engage, innovate, and adopt AI solutions. Table 3 provides a summary of how operational and organizational functional domains map across the papers.

Leadership Skills and Behaviors for Preparing Health Care Organizations for AI Transformation

We categorized the themes related to skills and behaviors into 3 essential capacities that a leader must demonstrate to achieve desired goals—technical capacity, adaptive capacity, and interpersonal capacity. Technical capacity encompasses (1) AI literacy, (2) subject matter knowledge, (3) change leadership skills, and (4) innovation mindset to identify AI innovation opportunities. The interpersonal capacity involves several vital facets such as (1) the ability to foster partnerships among diverse stakeholders, (2) the ability to comprehend diverse stakeholder perspectives and deftly influence adoption, (3) the ability to build trust and collaboration, (4) self-awareness and humility to assemble teams with complementary skills, and (5) the integrity and accountability to embody ethical principles. The adaptive capacity encompasses (1) the foresight and sense-making abilities to discern emerging technologies and their implications within the health care sphere; (2) the agility to identify and capitalize on transformative opportunities, swiftly adapting and aligning strategies with evolving contexts; and (3) systems thinking to enable an understanding of how elements interconnect and how changes in 1 area can reverberate throughout the entire system.

Contextual Factors Influencing Leadership in AI Transformation

The emerging themes from our review reveal that dynamic environmental and situational factors, including regulatory, technology, and organizational contexts, shape AI transformation within health care organizations. For instance, the regulatory context and frameworks related to health professions and health care organizations play a critical role in how AI can be integrated within the organizations. Similarly, the technology context such as the availability of AI technical talent, the retention of technical expertise, the dynamic nature of AI maturity, and the presence of incentives and technological resources for AI innovation or adoption will significantly influence a leader’s ability to effectively drive AI readiness. Finally, the organization context is a critical influence on leaders’ capacity for AI adoption and implementation. Organizations that promote and reward innovation and that have transparent communication practices shape leaders’ ability to pursue AI opportunities.

Strategies for Empowering Health Care Leaders to Facilitate AI Transformation

For the technological domain, the included papers discussed approaches such as upskilling clinical experts with the necessary AI technical skills and ensuring the presence of specialized experts, such as computer scientists, to enable the subject matter experts to develop, test, and seamlessly integrate AI solutions. Further, the papers discussed collaborative strategies such as clinicians and computer scientists working together to effectively identify AI opportunities and develop, adopt, and implement AI solutions in clinical or operational areas.

For the strategic domain, organizational support was essential in supporting leaders to assess and identify AI opportunities that strategically align with organizational priorities and develop strategies to ensure AI transformation garners support from key stakeholders within the complex regulatory and environmental contexts. The literature also highlighted the competition for AI talent in health care and emphasized the significance of talent retention strategies to preserve the organization’s AI technical expertise.

Then, in the operational domain, the emphasis was on establishing governance structures to continuously monitor data quality, patient privacy, and patient care experiences and assess the feasibility and financial implications of AI transformation. These governance structures ensure effective oversight and management of AI initiatives within health care organizations.

Finally, for the organizational domain, the focus was on the pivotal role of organizational culture in AI leadership. Leaders require organizational support to cultivate an environment that fosters innovation and actively incentivizes clinical leaders, such as physicians and nurses, through protected time and incentive pay to innovate and adopt AI solutions. Transparent decision-making processes related to AI solutions are essential cultural elements that build trust in AI systems and promote collaboration among the diverse stakeholders involved in AI transformation within health care organizations.

Principal Findings

The purpose of a scoping review is not to draw definitive conclusions but to map the literature, identify emerging patterns, and develop critical propositions. As described in Figure 2 , analysis of current literature shows that leading organizations toward AI transformation requires multidimensional leadership. As such, health care organizations need to engage leaders in the technological, strategic, operational, and organizational domains to facilitate AI transformation in their organizations. Further, the reviewed papers suggest that individuals in AI-related leadership roles need to demonstrate (1) technical capacity to understand the technology and innovation opportunities, (2) adaptive capacity to respond to contextual changes, and (3) interpersonal capacity to navigate the human aspects of the AI transformation process effectively. Furthermore, our study illuminates that leaders in the AI-related leadership roles need to navigate regulatory context, the dynamic nature of changing technology context, and organization context.

Prior Research

Health care organizations are marked by multifaceted interdependencies among medical facilities, health care providers, patients, administrative units, technology, and the regulatory environment. Therefore, the leadership required for AI transformation—which includes identifying AI opportunities, implementing AI solutions, and achieving full-scale AI adaptation—is not a static role but a continuous and dynamic process. Effective leadership involves the capacity to continuously identify opportunities for AI transformation, influence the thoughts and actions of others, and navigate the complex dynamics of the health care setting and AI technology landscape simultaneously. However, the current literature has not fully articulated this multidimensionality, often focusing on leadership through a linear approach.

Further, multiple situational factors can shape AI transformation. First, the rapid growth of AI technologies introduces an element of uncertainty, making it challenging to anticipate the long-term impact and sustainability of specific AI solutions [ 6 ]. Second, AI implementation involves many stakeholders, from technical experts and domain specialists to clinicians, administrators, patients, vendors, and regulatory bodies. Each stakeholder group brings its unique perspectives, priorities, and control systems into the equation, necessitating leaders to navigate competing values, trade-offs, and paradoxes [ 27 ]. Third, once alignment is achieved, the integration of AI within an organization triggers a need for a cultural shift, altering work practices and decision-making processes [ 38 , 59 ]. Fourth, the effectiveness of AI solutions hinges on the availability of high-quality data for informed insights and decision-making. When implementing solutions originally developed within different contexts, local organizations must ensure data integrity and the solution’s adaptability to the organization’s unique context [ 18 ]. This challenge is compounded by emerging regulatory frameworks, which add a layer of complexity. Ensuring compliance and the responsible use of AI technologies has become a critical consideration [ 29 , 50 , 60 ]. Finally, introducing AI may provoke resistance from employees concerned about job displacement or disruptions to established workflows. This problem is further compounded when an organization transitions toward integrating multiple AI systems, as these changes can lead to periods of chaos and confusion [ 59 ].

Emerging key opinions and evidence from outside the health domain indicate that leaders must possess an understanding of data quality nuances, assess process risks, and manage AI as a new team member. Additionally, leaders should have a firm grasp of technology, articulate clear business objectives, define precise goals, uphold a long-term vision, prepare their teams for AI transformation, manage data resources effectively, and foster organizational collaboration [ 3 , 61 - 67 ].

Our findings on the leadership required for AI transformation in health care organizations reinforce this multidimensionality of leadership to effectively navigate the complexities of AI transformation and successfully leverage its potential to drive transformative change. Leaders must operate across different functional domains—technological, strategic, operational, and organizational—while demonstrating technical, adaptive, and interpersonal capacities.

Further, our findings show contingency leadership theories, complexity theory, and transformational leadership theory as relevant theoretical domains for further explaining the different facets of leadership behaviors needed to navigate the multidimensionality of leadership required for AI transformation.

Contingency theories suggest that leadership effectiveness depends on situational factors, which should be considered in future AI implementation studies in the context of AI adaptation and integration within health care organizations [ 68 , 69 ]. Complexity theory provides a framework for examining leadership behaviors in interconnected, dynamic environments where leaders must balance innovation and stability and demonstrate an adaptive approach to challenges, characterized by uncertainty and change [ 70 - 73 ]. Transformational leadership theory emphasizes motivating, empowering, and developing others by fostering trust and collaboration while challenging the status quo to drive organizational change and innovation [ 74 , 75 ]. These theories should be considered in future AI implementation studies within health care organizations.

Future research and training programs related to AI in health care should examine the leadership required for AI transformation through the lens of multidimensionality, providing insights into the interrelatedness of functional domains, leadership capacities, and contextual enablers and barriers, while exploring the key theoretical domains related to contingency, complexity, and transformational leadership to further understand the interpersonal dynamics shaping AI transformation in health care.

Limitations

Some limitations to our scoping review are worth noting. First, given the contextual variability in the included studies and the methodological variations, we could not establish firm correlations about specific leadership domains, capacities, and contextual factors; the effectiveness of leadership approaches; or the moderating effects of contextual factors. Consequently, we have presented only the overarching emergent themes.

Second, our study is limited by the significant variation in conceptual definitions of leadership and leadership competencies found in the current literature, which often lacks more standardized definitions or instruments for measurement. This variation caused conceptual inconsistencies. We addressed the inconsistencies by clearly defining what constitutes a functional domain, capacity, and context before our data analysis to address this. We iteratively coded the data into themes to ensure all relevant aspects were captured.

Third, our search strategy focused on MEDLINE-indexed journals, which may exclude some newer journals indexed in PubMed but not yet in MEDLINE. While this might limit the capture of the very latest advancements in digital health, it does not diminish the robustness of the review. Fourth, we retrieved only articles written in English, which possibly limited the comprehensiveness of our findings. Fifth, we looked at AI as a system and did not look at the relationship between the implementation of different types of AI tools and leadership behaviors which was beyond the scope of our review. Finally, our analysis used an inductive approach and was not informed by a predetermined theory to aid the mapping of the literature. This may have limited our analysis in capturing different elements of an umbrella theory.

Recommendations for Future Design and Research

Leading organizations toward AI transformation is an adaptive challenge influenced by a myriad of interwoven situational factors that create a dynamic and intricate environment. The body of literature related to AI in health care is rapidly expanding, and the recommendations imparted by this review, alongside the multidimensional leadership framework ( Figure 2 ), stand poised to guide research and practice to empower health care organizations in their AI transformation journey. Future research on AI transformation, which includes innovation identification, implementation, and scaling, can use this framework to understand the role of leadership in driving successful outcomes.

Further, future research must undergo methodological expansion by embracing qualitative and mixed methods approaches to illuminate the intricate temporal aspects of AI transformation and corresponding evolving leadership behaviors.

Conclusions

In summary, emerging evidence shows that multidimensional leadership plays crucial role in AI transformation in health care organization. Leaders must adeptly balance technology opportunities while demonstrating unwavering empathy for stakeholder needs and nimble adaptability to accommodating the ever-changing contextual landscape, which encompasses the regulatory frameworks, the evolution of technology, and the organization’s priorities.

Acknowledgments

This work is supported through a grant from the University of Toronto’s Connaught Global Challenges. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the study.

Data Availability

The main study data are the data extraction materials and quality ratings of included papers, most of which are included in the study tables. The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

All authors were involved in conception and design of the study and approved the protocol. AS and NS were responsible for overseeing the search of databases and literature. AS, NS, and SS were involved in the screening of articles, data extraction and data verification, and analysis of data. All authors were involved in data interpretation, supported in the drafting of the paper, which was led by AS, and all authors supported in revising and formatting of the paper. All authors have provided final approval of the version of the paper submitted for publication, and all authors agree to be accountable for all aspects of the work.

Conflicts of Interest

None declared.

Updated PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist.

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Abbreviations

Edited by T de Azevedo Cardoso, G Eysenbach; submitted 14.11.23; peer-reviewed by D Chrimes, TAR Sure, S Kommireddy, J Konopik, M Brommeyer; comments to author 20.02.24; revised version received 12.03.24; accepted 15.07.24; published 14.08.24.

©Abi Sriharan, Nigar Sekercioglu, Cheryl Mitchell, Senthujan Senkaiahliyan, Attila Hertelendy, Tracy Porter, Jane Banaszak-Holl. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 14.08.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.