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Research Article

The impact of engaging leadership on employee engagement and team effectiveness: A longitudinal, multi-level study on the mediating role of personal- and team resources

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliation Department of Education Studies, University of Bologna, Bologna, Italy

Roles Conceptualization, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing

Affiliations Research Unit Occupational & Organizational Psychology and Professional Learning, KU Leuven, Belgium, Department of Psychology, Utrecht University, Utrecht, The Netherlands

• Greta Mazzetti, 
• Wilmar B. Schaufeli

• Published: June 29, 2022
• https://doi.org/10.1371/journal.pone.0269433
• Reader Comments

Most research on the effect of leadership behavior on employees’ well-being and organizational outcomes is based on leadership frameworks that are not rooted in sound psychological theories of motivation and are limited to either an individual or organizational levels of analysis. The current paper investigates whether individual and team resources explain the impact of engaging leadership on work engagement and team effectiveness, respectively. Data were collected at two time points on N = 1,048 employees nested within 90 work teams. The Multilevel Structural Equation Modeling results revealed that personal resources (i.e., optimism, resiliency, self-efficacy, and flexibility) partially mediated the impact of T1 individual perceptions of engaging leadership on T2 work engagement. Furthermore, joint perceptions of engaging leadership among team members at T1 resulted in greater team effectiveness at T2. This association was fully mediated by team resources (i.e., performance feedback, trust in management, communication, and participation in decision-making). Moreover, team resources had a significant cross-level effect on individual levels of engagement. In practical terms, training and supporting leaders who inspire, strengthen, and connect their subordinates could significantly improve employees’ motivation and involvement and enable teams to pursue their common goals successfully.

Citation: Mazzetti G, Schaufeli WB (2022) The impact of engaging leadership on employee engagement and team effectiveness: A longitudinal, multi-level study on the mediating role of personal- and team resources. PLoS ONE 17(6): e0269433. https://doi.org/10.1371/journal.pone.0269433

Editor: Ender Senel, Mugla Sitki Kocman University: Mugla Sitki Kocman Universitesi, TURKEY

Received: December 29, 2021; Accepted: May 23, 2022; Published: June 29, 2022

Copyright: © 2022 Mazzetti, Schaufeli. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data that support the findings of this study are available on Open Science Framework (OSF) website at the following link: https://osf.io/yfwgt/?view_only=c838730fd7694a0ba32882c666e9f973 . DOI: https://doi.org/10.17605/OSF.IO/YFWGT .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Multiple studies suggest that work engagement, which is defined as a positive, work-related state of mind characterized by vigor, dedication, and absorption [ 1 ], is related to extremely positive outcomes, particularly in terms of employees’ well-being and job performance (for a narrative overview see [ 2 ]; for a meta-analysis see [ 3 ]).

Therefore, when work engagement is arguably beneficial for employees and organizations alike, the million-dollar question (quite literally, by the way) is: how can work engagement be increased? Schaufeli [ 4 ] has argued that operational leadership is critical for enhancing follower’s work engagement. Based on the logic of the Job Demands-Resources (JD-R) model [ 5 ], he reasoned that team leaders may (or may not) monitor, manage, and allocate job demands and resources to increase their follower’s levels of work engagement. In doing so, team leaders boost the motivational process that is postulated in the JD-R model. This process assumes that job resources and challenging job demands are inherently motivating and will lead to a positive, affective-motivational state of fulfillment in employees known as work engagement.

The current study focuses on a specific leadership style, dubbed engaging leadership and rooted in Self-Determination Theory (SDT) [ 6 ]. Engaging leaders inspire, strengthen, and connect their followers, thereby satisfying their basic psychological needs of autonomy, competence, and relatedness, respectively. In line with the motivational process of the JD-R model, cross-sectional evidence suggests that engaging leaders increase job resources [ 7 ] and personal resources [ 8 ], which, in their turn, are positively associated with work engagement. So far, the evidence for this mediation is exclusively based on cross-sectional studies. Hence, the first objective of our paper is to confirm the mediation effect of resources using a longitudinal design.

Scholars have emphasized that “the study of leadership is inherently multilevel in nature” (p. 4) [ 9 ]. This statement implies that, in addition to the individual level, the team level of analysis should also be included when investigating the impact of engaging leadership.

The current study makes two notable contributions to the literature. First, it investigates the impact, over time, of a novel, specific leadership style (i.e., engaging leadership) on team- and individual outcomes (i.e., team effectiveness and work engagement). Second, it investigates the mediating role of team resources and personal resources in an attempt to explain the impact of leadership on these outcomes. The research model, which is described in greater detail below, is displayed in Fig 1 .

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https://doi.org/10.1371/journal.pone.0269433.g001

Leadership and work engagement

Leadership is defined as the way in which particular individuals–leaders–purposefully influence other individuals–their followers–to obtain defined outcomes [ 10 ].

A systematic narrative review identified twenty articles on leadership and work engagement [ 11 ] and showed that work engagement is positively associated with various person-centered leadership styles. The most pervasively used framework was transformational leadership, whereas authentic, ethical, and charismatic leadership was used much less. The authors conclude that "most of the reviewed studies were consistent in arguing that leadership is significantly correlated with and is affecting employee’s work engagement directly or via mediation” (p. 18) [ 11 ]. Moreover, they also conclude that research findings and inferences on leadership and engagement remain narrowly focused and inconclusive due to the lack of longitudinal designs addressing this issue. A recent meta-analysis [ 12 ] identified 69 studies and found substantial positive relationships of work engagement with ethical (k = 9; ρ = .58), transformational (k = 36; ρ = .46) and servant leadership (k = 3; ρ = .43), and somewhat less strong associations with authentic (k = 17; ρ = .38) and empowering leadership (k = 4; ρ = .35). Besides, job resources (e.g., job autonomy, social support), organizational resources (e.g., organizational identification, trust), and personal resources (self-efficacy, creativity) mediated the effect of leadership on work engagement. Although transformational leadership is arguably the most popular leadership concept of the last decades [ 13 ], the validity of its conceptual definition has been heavily criticized, even to the extent that some authors suggest getting “back to the drawing board” [ 14 ]. It should be noted that three main criticisms are voiced: (1) the theoretical definition of the transformational leadership dimensions is meager (i.e., how are the four dimensions selected and how do they combine?); (2) no causal model is specified (i.e., how is each dimension related to mediating processes and outcomes?); (3) the most frequently used measurement tools are invalid (i.e., they fail to reproduce the dimensional structure and do not show empirical distinctiveness from other leadership concepts). Hence, it could be argued that the transformational leadership framework is not very well suited for exploring the impact of leadership on work engagement.

Schaufeli [ 7 ] introduced the concept of engaging leadership , which is firmly rooted in Self-Determination Theory. According to Deci and Ryan [ 6 ], three innate psychological needs are essential ‘nutrients’ for individuals to function optimally, also at the workplace: the needs for autonomy (i.e., feeling in control), competence (i.e., feeling effective), and relatedness (i.e., feeling loved and cared for). Moreover, SDT posits that employees are likely to be engaged (i.e., internalize their tasks and show high degrees of energy, concentration, and persistence) to the degree that their needs for autonomy, competence, and relatedness are satisfied [ 15 ]. This is in line with Bormann and Rowold [ 16 ]. Based on a systematic review on construct proliferation in leadership research, these authors recommended that leadership concepts should use SDT because this motivational theory allows a more parsimonious description of the mechanisms underlying leadership behaviors. These authors posited that the core of "narrow" leadership constructs "bases on a single pillar" (p. 163), and therefore predict narrow outcomes. In contrast to broad leadership constructs, the concept of engaging leadership is narrow because it focuses on leadership behaviors to explicitly promote work engagement.

Schaufeli [ 7 ] reasoned that leaders, who are instrumental in satisfying their followers’ basic needs, are likely to increase their engagement levels. More specifically, engaging leaders are supposed to: (1) inspire (e.g., by enthusing their followers for their vision and plans, and by making them feel that they contribute to something important); (2) strengthen (e.g., by granting their followers freedom and responsibility, and by delegating tasks); and (3) connect (e.g., by encouraging collaboration and by promoting a high team spirit among their followers). Hence, by inspiring, strengthening, and connecting their followers, leaders stimulate the fulfillment of their follower’s basic psychological needs for autonomy, competence, and relatedness, respectively, which, in turn, will foster work engagement.

The underlying mechanisms of the relationship between engaging leadership and work engagement are a major focus of research, as the construct of engaging leadership was built upon the identification of the leadership behaviors that are capable of stimulating positive outcomes by satisfying needs. The literature on engaging leadership provides empirical evidence for its indirect impact on followers’ engagement by fulfilling followers’ basic needs. This finding is consistent across occupational sectors and cultural contexts [ 17 – 19 ]. Further, the observation of a partial mediation effect for need satisfaction suggests the presence of a direct relationship between engaging leadership and engagement [ 20 , 21 ]. In their behaviors, engaging leaders are likely to improve their job characteristics to the point of stimulating greater engagement among their employees. This assumption has been corroborated by a recent longitudinal study that delved deeper into the association between engaging leadership and needs satisfaction [ 22 ]. That study found that the relationship between engaging leadership and basic needs satisfaction is mediated by enhanced levels of job resources (among them were improved feedback and skill use and better person-job fit). The fulfilment of those needs, in turn, resulted in higher levels of work engagement. Therefore, perceived job resources seem to play a crucial role in the causal relationship between engaging leadership and basic needs satisfaction. This evidence found support in a later two-wave full panel design with a 1-year time lag, where engaging leadership promoted employees’ perception of autonomy and social support from colleagues [ 23 ]. In addition, a recent study by Van Tuin and colleagues [ 24 ] revealed that engaging leadership is associated with increased perceptions of intrinsic organizational values (e.g., providing a contribution to organizational and personal development) and satisfaction of the need for autonomy which, in turn, may boost employees’ level of engagement.

A recent study investigated the ways in which engaging leadership could boost the effects of human resource (HR) practices for promoting employees’ psychological, physical, and social well-being over time [ 25 ]. Teams led by an engaging leader reported higher levels of happiness at work and trust in leadership, combined with lower levels of burnout than their colleagues who were led by poorly engaging leaders. Happiness and trust played a key role in improving team member performance. These findings indicate that engaged leaders provide a thoughtful implementation of HR practices focused on promoting employee well-being, being constantly driven by their employees’ flourishing.

Another line of studies may reveal the causality between engaging leadership and work-related outcomes. A multilevel longitudinal study provided cross-level and team-level effects of engaging leadership [ 26 ]. Engaging leadership at T1 explained team learning, innovation, and individual performance through increased teamwork engagement at T2. Interventions targeting engaging leadership created positive work outcomes for leaders (e.g., autonomy satisfaction and intrinsic motivation) and decreased employee absenteeism [ 27 ]. However, cross-lagged longitudinal analyses indicate that employees’ current level of work engagement predicts their leaders’ level of engaging leadership rather than the other way around [ 23 ]. These findings imply that the relationship between engaging leadership and work engagement cannot be narrowed to a simple unidirectional causal relationship but rather exhibits a dynamic nature, where engaging leadership and work engagement mutually influence each other. The dynamic nature of engaging leadership has also been investigated through a diary study. The results suggest that employees enacted job crafting strategies more frequently on days when leaders were more successful in satisfying their need for connectivity [ 28 ]. Hence, leaders who satisfy the need for connectedness among their followers will not only encourage higher levels of engagement among their followers but also an increased ability to proactively adapt tasks to their interests and preferences.

Since transformational leadership is currently the most frequently studied leadership style, a summary of the similarities and differences in the proposed new conceptualization of leadership proposed (i.e., engaging leadership) must be provided.

A key difference between transformational and engaging leadership originates from their foundation. Whereas transformational leadership is primarily a change-oriented style, engaging leadership encourages employees’ well-being through the promotion of supportive relationships and is defined as a relationship-oriented leadership style [ 29 ].

Further similarities entail the combination of behaviors meant to foster employees’ well-being and growth. Transformational leaders act as role models admired and emulated by followers (idealized influence), encourage a reconsideration of prevailing assumptions and work practices to promote stronger innovation (intellectual stimulation), identify and build on the unique characteristics and strengths of each follower (individualized consideration), and provides a stimulating view of the future and meaning of their work (inspirational motivation) [ 30 ]. A considerable resemblance involves the dimensions of inspirational motivation and inspiring, which are, respectively, included in transformational and engaging leadership. They both entail recognizing the leader as a guiding light to a specific mission and vision, where individual inputs are credited as essential ingredients in achieving the shared goal. Thus, they both fulfill the individual need for meaningfulness. In a similar vein, transformational and engaged leaders are both committed to promote followers’ growth in terms of innovation and creativity. In other words, the intellectual stimulation offered by transformational leadership and the strengthening component of engaging leadership are both aimed at meeting the need for competence among followers.

Alternatively, it is also possible to detect decisive differences between the dimensions underlying these leadership styles. Transformational leadership entails the provision of personal mentorship (i.e., individualized consideration), while engaging leadership is primarily focused on enhancing the interdependence and cohesion among team members (i.e., team consideration). Furthermore, engaging leadership disregards the notion of idealized influence covered by transformational leadership: an engaging leader is not merely identified as a model whose behavior is admired and mirrored, but rather proactively meets followers’ need for autonomy through the allocation of tasks and responsibilities.

Empirical results lent further support to the distinctiveness between transformational and engaging leadership. The analysis of the factor structure of both constructs revealed that measures of engaging and transformational leadership load on separate dimensions instead of being explained by a single latent factor [ 31 ]. More recently, additional research findings pointed out that engaging and transformational leadership independently account for comparable portions of variance in work engagement [ 32 ]. However, this does not alter the fact that a certain overlap exists between both leadership concepts; thus, it is not surprising that a consistent, positive relationship is found between transformational leadership and work engagement [ 11 ].

In sum: a positive link appears to exist between person-centered leadership styles and work engagement. Moreover, this relationship seems to be mediated by (job and personal) resources. However, virtually all studies used cross-sectional designs, and the causal direction remains unclear. We followed the call to go back to the drawing board by choosing an alternative, deductive approach by introducing the theory-grounded concept of engaging leadership and investigate its impact on individual and team outcomes (see Fig 1 ).

Engaging leadership, personal resources, and employee engagement (individual level)

Serrano and Reichard [ 33 ], who posit that leaders may pursue four pathways to increase their follower’s work engagement: (1) design meaningful and motivating work; (2) support and coach their employees; (3 ) facilitate rewarding and supportive coworker relations, and (4) enhancing personal resources. In the present study, we focus on the fourth pathway. Accordingly, a cross-sectional study using structural equation modeling [ 8 ] showed that psychological capital (i.e., self-efficacy, optimism, resiliency, and flexibility) fully mediated the relationship between perceived engaging leadership and follower’s work engagement. Consistent with findings on job resources, this study indicated that personal resources also mediate the relationship between engaging leadership and work engagement. In a nutshel, when employees feel autonomous, competent, and connected to their colleagues, their own personal resources benefit, and this fuels their level of engagement.

In the current study, we use the same conceptualization of psychological capital (PsyCap) as Schaufeli [ 7 , 8 ], which slightly differs from the original concept. Originally, PsyCap was defined as a higher-order construct that is based on the shared commonalities of four first-order personal resources: “(1) having confidence (self-efficacy) to take on and put in the necessary effort to succeed at challenging tasks; (2) making a positive attribution (optimism) about succeeding now and in the future; (3) persevering toward goals and, when necessary, redirecting paths to goals (hope) to succeed; and (4) when beset by problems and adversity, sustaining and bouncing back and even beyond (resiliency) to attain success” (p. 10) [ 34 ]. Instead of hope, flexibility is included; that is, the capability of employees to adapt to new, different, and changing requirements at work. Previous research showed a high correlation ( r > .70) between hope and optimism, thus increasing the risk of multicollinearity [ 35 ]. This strong relationship points at conceptual overlap: hope is defined as the perception that goals can be set and achieved, whereas optimism is the belief that one will experience good outcomes. Hence, trust in achieving goals (hope) implies optimism. Additionally, hope includes "when necessary, redirecting paths to goals", which refers to flexibility. Finally, in organizational practice, the flexibility of employees is considered an essential resource because organizations are continuously changing, which requires permanent adaption and hence employee flexibility. In short, there are psychometric, conceptual, and pragmatic arguments for replacing hope by flexibility.

According to Luthans and colleagues [ 36 ], PsyCap is a state-like resource representing an employee’s motivational propensity and perseverance towards goals. PsyCap is malleable and open to development, thus it can be enhanced through positive leadership [ 37 ]. Indeed, it was found that transformational leadership enhances PsyCap, which, in turn, increases in-role performance and organizational citizenship behavior [ 38 ]. In a similar vein, PsyCap mediates the relationships between authentic leadership and employee’s creative behavior [ 39 ].

We argue that engaging leadership may promote PsyCap as well. After all, by inspiring followers with a clear, powerful and compelling vision, engaging leaders: (1) create the belief in their ability to perform tasks that tie in with that vision successfully, thereby fostering follower’s self-efficacy ; (2) generate a positive appraisal of the future, thereby fostering follower’s optimism ; (3) trigger the ability to bounce back from adversity because a favorable future is within reach, thereby fostering follower’s resiliency ; (4) set goals and induce the belief that these can be achieved, if necessary by redirecting paths to those goals, thereby fostering follower’s flexibility [ 38 ].

Furthermore, engaging leaders strengthen their followers and unleash their potential by setting challenging goals. This helps to build followers’ confidence in task-specific skills, thereby increasing their self-efficacy levels, mainly via mastery experiences that occur after challenging goals have been achieved [ 40 ]. Setting high-performance expectations also elevates follower’s sense of self-worth, thereby leading to a positive appraisal of their current and future circumstances (i.e., optimism ). Moreover, a strengthening leader acts as a powerful contextual resource that augments followers’ self-confidence and, hence, increases their ability to bounce back from adversity (i.e., resiliency ) and adapt to changing requirements at work (i.e., flexibility ).

Finally, by connecting their followers, engaging leaders promote good interpersonal relationships and build a supportive team climate characterized by collaboration and psychological safety. Connecting leaders also foster commitment to team goals by inducing a sense of purpose, which energizes team members to contribute toward the same, shared goal. This means that in tightly knit, supportive and collaborative teams, followers: (1) experience positive emotions when team goals are met, which, in turn, fosters their level of self-efficacy [ 40 ]; (2) feel valued and acknowledged by others, which increases their self-worth and promotes a positive and optimistic outlook; (3) can draw upon their colleagues for help and support, which enables to face problems and adversities with resiliency ; (4) can use the abilities, skills, and knowledge of their teammates to adapt to changing job and team requirements (i.e., flexibility ).

In sum, when perceived as such by followers, engaging leadership acts as a sturdy contextual condition that enhances their PsyCap. We continue to argue that, in its turn, high levels of PsyCap are predictive for work engagement; or in other words, PsyCap mediates the relationship between engaging leadership and work engagement.

How to explain the relationship between PsyCap and work engagement? Sweetman and Luthans [ 41 ] presented a conceptual model, which relates PsyCap to work engagement through positive emotions. They argue that all four elements of PsyCap may have a direct and state-like relationship with each of the three dimensions of work engagement (vigor, dedication, and absorption). Furthermore, an upward spiral of PsyCap and work engagement may be a source of positive emotion and subsequently broaden an employee’s growth mindset, leading to higher energy and engagement [ 42 , 43 ]. In short, PsyCap prompts and maintains a motivational process that leads to higher work engagement and may ultimately result in positive outcomes, such as job satisfaction and organizational commitment [ 44 ].

Psychological capital is a valuable resource to individuals [ 45 ] that fosters work engagement, as demonstrated in past research [ 46 ]. Hence, following the reasoning above, we formulate the following hypothesis:

• Hypothesis 1: Psychological capital (self-efficacy , optimism , resiliency , and flexibility) mediates the relationship between T1 employee’s perceptions of engaging leadership and T2 work engagement .

Engaging leadership, team resources, and work team effectiveness (team level)

So far, we focused on individual-level mediation, but an equivalent mediation process is expected at the aggregated team level as well. We assume that leaders display a comparable leadership style toward the entire team, resulting in a similar relationship with each of the team members. This model of leader-follower interactions is known as the average leadership style (ALS) [ 47 ]. This means that homogeneous leader-follower interactions exist within teams, but relationships of leaders with followers may differ between teams. The relationships between leadership and team effectiveness might be based on an analogous, team-based ALS-approach as well [ 48 ]. Following this lead, we posit that team members share their perceptions of engaging leadership, while this shared perception differs across teams. Moreover, we assume that these shared perceptions are positively related to team effectiveness.

An essential role for leaders is to build team resources, which motivate team members and enable them to perform. Indeed, the influence of leader behaviors on team mediators and outcomes has been extensively documented [ 49 , 50 ].

Most studies use the heuristic input-process-output (IPO) framework [ 51 ] to explain the relationship between leadership (input) and team effectiveness (output), whereby the intermediate processes describe how team inputs are transformed into outputs. It is widely acknowledged that two types of team processes play a significant role: “taskwork” (i.e., functions that team members must perform to achieve the team’s task) and “teamwork” (i.e., the interaction between team members, necessary to achieve the team’s task). Taskwork is encouraged by task-oriented leadership behaviors that focus on task accomplishment. In contrast, teamwork is encouraged by person-oriented leadership behaviors that focus on developing team members and promoting interactions between them [ 49 ]. The current paper focuses on teamwork and person-oriented (i.e., engaging) leadership.

Collectively, team resources such as performance feedback, trust in management, communication between team members, and participation in decision-making constitute a supportive team climate that is conducive for employee growth and development, and hence fosters team effectiveness, as well as individual work engagement. This also meshes with Serrano and Reichard [ 33 ], who argue that for employees to flourish, leaders should design meaningful and motivating work (e.g., through feedback and participation in decision making) and facilitate rewarding and supportive coworker relations (e.g., through communication and trust in management).

To date, engaging leadership has not been studied at the team level and concerning team resources and team effectiveness. How should the association between engaging leadership and team resources be conceived? By strengthening, engaging leaders provide their team members with performance feedback; by inspiring, they grant their team members participate in decision making; and by connecting, they foster communication between team members and install trust. Please note that team resources refer to shared, individual perceptions of team members, which are indicated by within-team consensus. Therefore, taken as a whole, the team-level resources that are included in the present study constitute a supportive team climate that is characterized by receiving feedback, trust in management, communication amongst team members, and participating in decision-making. We have seen above that engaging leaders foster team resources, but how are these resources, in their turn, related to team effectiveness?

The multi-goal, multi-level model of feedback effects of DeShon and colleagues [ 52 ] posits that individual and team regulatory processes govern the allocation of effort invested in achieving individual and team goals, resulting in individual and team effectiveness. We posit that the shared experience of receiving the team leader’s feedback prompts team members to invest efforts in achieving team tasks, presumably through team regulatory processes, as postulated in the multi-goal, multi-level model.

Trust has been defined as: “the willingness of a party to be vulnerable to the actions of another party based on the expectation that the other party will perform a particular action to the trustor, irrespective of the ability to monitor or control that other party” (p. 712) [ 53 ]. Using a multilevel mediation model, Braun and colleagues [ 54 ] showed that trust mediates the relationship between transformational leadership and performance at the team level. They reasoned that transformational leaders take into account a team member’s needs, goals, and interests, making them more willing to be vulnerable to their supervisor. This would apply even more for engaging leaders, which is defined in terms of satisfying basic follower’s needs. It is plausible that a team’s shared trust in its leader enhances the trust of team members in each other. That means that team members interact and communicate trustfully and rely on each other’s abilities, which, in turn, is conducive for team effectiveness [ 55 ].

Communication is a crucial element of effective teamwork [ 56 ]. Team members must exchange information to ascertain other members’ competence and intentions, and they must engage in communication to develop a strategy and plan their work. Several studies have shown that effectively gathering and exchanging information is essential for team effectiveness [ 57 , 58 ]. Furthermore, participation in decision-making is defined as joint decision-making [ 59 ] and involves sharing influence between team leaders and team members. By participating in decision-making, team members create work situations that are more favorable to their effectiveness. Team members utilize participating in decision-making for achieving what they desire for themselves and their team. Generally speaking, shared mental models are defined as organized knowledge structures that allow employees to interact successfully with their environment, and therefore lead to superior team performance [ 60 ]. That is, team members with a shared mental model about decision-making are ‘in sync’ and will easily coordinate their actions, whereas the absence of a shared mental model will result in process loss and ineffective team processes.

Taken together and based on the previous reasoning, we formulate the second hypothesis as follows:

• Hypothesis 2: Team resources (performance feedback , trust in management , team communication , and participation in decision-making) mediate the relationship between T1 team member’s shared perceptions of engaging leadership and T2 team effectiveness .

Engaging leadership, team resources, and work engagement (cross-level)

Engaging leaders build team resources (see above). Or put differently, the team member’s shared perceptions of engaging leadership are positively related to team resources. Besides, we also assume that these team resources positively impact work engagement at the individual level. A plethora of research has shown that various job resources are positively related to work engagement, including feedback, trust, communication, and participation in decision- making (for a narrative overview see [ 61 ]; for a meta-analysis see [ 62 , 63 ]). Most research that found this positive relationship between job resources and work engagement used the Job-Demands Resources model [ 5 ] that assumes that job resources are inherently motivating because they enhance personal growth and development and are instrumental in achieving work goals. Typically, these resources are assessed as perceived by the individual employee. Yet, as we have seen above, perceptions of resources might also be shared amongst team members. It is plausible that these shared resources, which collectively constitute a supportive, collaborative team climate, positively impact employee’s individual work engagement. Teams that receive feedback, have trust in management, whose members amply interact and communicate, and participate in decision-making are likely to produce work engagement. This reasoning agrees with Schaufeli [ 64 ], who showed that organizational growth climate is positively associated with work engagement, also after controlling for personality. When employee growth is deemed relevant by the organization this is likely to translate, via engaging leaders, into a supportive team environment, which provides feedback, trust, communication, and participative decision-making. Hence, we formulate:

• Hypothesis 3: Team resources (performance feedback , trust in management , team communication , and participation in decision-making) mediate the relationship between team shared perceptions of engaging leadership at T1 and individual team member’s work engagement at T2 .

Sample and procedure

In collaboration with the HR department, data were collected among all employees of a business unit of a large Dutch public service agency. This agency is responsible for the administration of unemployment benefits and work incapacitation claims, as well as for the rehabilitation and return to work of unemployed and incapacitated employees. A one-year time-lagged design was applied to minimize the likelihood of common method variance effects and to explore causal relationships among the study variables [ 65 ]. The questionnaire included a cover letter reporting the aims and contents of the study. The letter also stated that participation in the study was completely voluntary, and that one can withdraw from the study at any time without having to give explanations and without this involving any disadvantage or prejudice. Participants’ consent was concluded by conduct, through ticking the consent checkbox as a prerequisite to access the questionnaire. This research was conducted in 2015, thus before the publication of the General Data Protection Regulation (GDPR) and complied with the latest version of the Declaration of Helsinki. Thus, ethics approval was not compulsory, as per applicable institutional and national Dutch guidelines. Additionally, the current study did not involve any treatment, medical diagnostics, or procedures generating psychological or social discomfort among participants.

In the first survey at Time 1 ( N = 2,304; response rate 63%), employees were asked about their socio-demographic background, engaging leadership, team resources (i.e., performance feedback, trust in management, communication, and participation in decision-making), team effectiveness, personal resources (i.e., resiliency, optimism, and flexibility), and work engagement. At Time 2 ( N = 2,183; response rate 51%), participants filled out the same survey, which included an additional self-efficacy scale. At both measurement points, participants received an email from the HR department containing a link that allowed them to fill out the online survey. This introductory email provided background information about the study’s general aim and guaranteed that participants’ responses would be treated confidentiality. A sample of N = 1,048 employees filled out the questionnaire twice, with an interval of one year between T1 and T2.

The estimation of multilevel models with at least 50 teams of at least 5 members per group is strongly recommended to avoid underestimating standard errors and variances for random effects [ 66 , 67 ]. Therefore, participants being part of teams with less than 5 employees were excluded from the analyses. Accordingly, the data of 1,048 participants, who completed both questionnaires, could be linked and constitute the current study sample. Employees were nested within 90 work teams, with an average of 13.7 ( SD = 5.72) employees per team. Slightly more women (51.8%) as men were included (48.2%), the average age of the sample was 49.70 years ( SD = 7.46), and the mean organization tenure was 12.02 years ( SD = 9.56).

All measures described below were rated using five-point scales that either ranged from strongly disagree (1) to strongly agree (5), or from never (1) to always (5). The internal consistencies (Cronbach’s α) of the measures are displayed on the diagonal of Table 2 .

Engaging Leadership was measured using a scale developed by Schaufeli [ 64 ] including nine items. This questionnaire contains three subscales of three items each: Inspiring, Strengthening, and Connecting. Sample items are: “My supervisor is able to enthuse others for his/her plans” (inspiring); “My supervisor delegates tasks and responsibilities” (strengthening); and “My supervisor encourages team members to cooperate” (connecting).

Individual-level measures.

Optimism was measured with three items from the Optimism scale of the PsyCap Questionnaire developed by Luthans and colleagues [ 36 ], which is aimed at assessing employees’ expectations about future success at work because of a positive view of their job. A sample item is: “I always look on the bright side of things regarding my job”.

Resiliency was assessed using three items from the Resiliency scale of the PsyCap Questionnaire [ 36 ]. These items refer to employees’ beliefs about their ability to recover from uncertainty and failure and to react successfully to setbacks that can occur at work. A sample item is: "I usually take stressful things at work in stride”.

Self-efficacy referred to the perceived capability to efficiently plan and implement courses of action required to attain a specific work goal and was measured using three items from Mazzetti, Schaufeli, and Guglielmi [ 68 ]. A sample item is: "At work, I reach my goal even when unexpected situations arise".

Flexibility refers to the individual ability to adapt to changes in the workplace and to modify one’s schedules and plans to meet job requirements. It was assessed by using three items: "If the job requires, I am willing to change my schedule”; “I do not have problems changing the way I work” and “I adapt easily to changes at work”.

Work engagement was assessed using a three-item scale developed by Schaufeli and colleagues [ 69 ]. This ultra-short version of the Utrecht Work Engagement Scale has similar psychometric properties as the nine-item version. A sample item is: "At my work, I feel bursting with energy”.

Team-level measures.

Performance feedback was assessed by the three-item scale from the Questionnaire on the Experience and Evaluation of Work (QEEW) [ 70 ]. A sample item is: “Do you get enough information about the result of your work?”.

Trust in Management of team members was assessed using two items from Schaufeli [ 7 ]: “I trust the way my organization is managed”, and “I have confidence in my immediate supervisor”. Following the recommendations from Eisinga and colleagues [ 71 ] we computed the Spearman-Brown coefficient, since it represents the most appropriate reliability coefficient for a two-item scale ( r s = .43, p < .001).

Communication , meaning the perception of an efficient and prompt circulation of information at the team level was measured using the three-item Communication scale taken from the QEEW [ 70 ]. A sample item is: "I am sufficiently informed about the developments within my team”.

Participation in decision-making was measured by a single item (i.e., “Can you participate in decision making about work-related issues?”) from the QEEW [ 70 ].

Team effectiveness . The team-level criterion variable was assessed with a three-item scale [ 8 ]. A sample item is: “Do you cooperate effectively with others in your team?”.

In order to check for systematic dropout, the social-demographic background, as well as the scores on the study variables were compared of those employees in the panel who filled out the questionnaire twice at T1 and T2 ( N = 1,142) and those who dropped out and filled out the questionnaire only once at T1 ( N = 1,161). It appeared that compared to the group who dropped out, the panel group was slightly younger (t (2301) = -2.21; p < .05) and had less organizational tenure (t (2301) = -4.05; p < .001). No gender differences were observed between both groups (χ 2 = .88; n . s .). A multivariate analysis of variance (MANOVA) that included all study variables revealed a significant between-groups effect: F (12,2291) = 3.54, p < .001. Subsequent univariate tests showed that compared to the dropouts, the panel group scored higher on inspiring (F (1,2302) = 14.90, p < .001), strengthening (F (1,2302) = 9.39, p < .01), and connecting leadership (F (1,2302) = 14.90, p < .05), as well as on optimism (F (1,2302) = 5.59, p < .05), flexibility (F (1,2302) = 12.56, p < .001), work engagement (F (1,2302) = 9.16, p < .05), performance feedback (F (1,2302) = 11.68, p < .01), and participation in decision making (F (1,2302) = 8.83, p < .05). No significant differences were found for resiliency, trust in management, communication, and team effectiveness.

It seems that, taken together, the panel group is slightly younger and less tenured, and scores more favorable than the dropouts on most study variables. However, the differences between both groups are relatively small and vary between 0 and .13 on a 5-point scale. Therefore, it is not likely that systematic dropout has influenced the results of the current study.

Control variables.

At the individual level, we controlled for the potential confounding effects of gender, age, and tenure by including these variables as covariates in our analyses. More specifically, the impact of age was controlled for because previous research suggested that older employees report higher levels of personal resources [ 72 ] and work engagement [ 73 ]. Gender was also included as a control variable because previous research suggested that compared to women, men score lower on work engagement [ 74 ] and higher on personal resources, such as optimism and self-efficacy [ 75 ]. Finally, previous investigations also revealed that job tenure may affect employees’ level and stability of work engagement, with tenured employees reporting higher and more stable levels of work engagement compared to newcomers [ 76 ]. Besides, Barbier and colleagues [ 77 ] suggested that job tenure might affect employees’ personal resources (i.e., self-esteem and optimism). Considering this empirical evidence, job tenure was also included as a covariate in our model.

Data aggregation.

Our research model includes the three dimensions of engaging leadership (i.e., inspiring, strengthening, and connecting) three team resources (i.e., performance feedback, trust in management, communication and participation in decision-making), and one outcome (i.e., team effectiveness) at the team level of analysis. To check the reliability and validity of aggregated scores at the team level, four indices were computed [ 78 ]: (1) ICC [1] , which indicates the proportion of variance in ratings due to team membership; (2) ICC [2] , representing the reliability of between-groups differences; (3) r wg(j) , that measures the level of agreement within work teams; (4) deff , that measures the effect of independence violations on the estimation of standard errors through the formula 1+(average cluster size-1)*ICC [ 79 ]. Generally speaking, values greater than .05 for ICC [1] [ 80 ] and .40 for ICC [2] [ 81 ] an r wg(j) higher than .70, and a deff- index exceeding 2 are considered a prerequisite for aggregating data [ 78 ]. Moreover, one-way analysis of variance (ANOVA) was performed to explore whether participants’ scores on the Level 2 constructs differed significantly among work teams. The results of the aggregation tests are displayed in Table 1 . Taken together, these results justify the aggregation of the team-level variables.

https://doi.org/10.1371/journal.pone.0269433.t001

Strategy of analysis

To test our hypotheses, a multilevel structural equation modeling (MSEM) was tested using the Mplus 7 statistical modeling software [ 82 ]. The application of this procedure allows the inclusion of latent variables that take measurement errors into account and permits the simultaneous estimation of mediation effects at the individual and team levels; therefore, it is superior to stepwise approaches [ 83 ]. As suggested by Zhang and colleagues [ 84 ], predictors at the individual level (i.e., engaging leadership dimensions and personal resources) were team-mean centered using a centering within context – CWC approach [ 85 ]. This procedure was aimed at preventing the confounding effect of mediation within and between work teams. In other words, predictors at the individual level for subject i were centered around the mean of the cluster j to which case i belongs (i.e., predictor ij —M predictor j ). Accordingly, the latent engaging leadership factor at within-level was indicated by the CWC means of the three dimensions of engaging leadership (i.e., inspiring cwc , strengthening cwc , and connecting cwc ) at T1. In a similar vein, personal resources were included as a latent variable indicated by the observed levels of optimism cwc , reisliency cwc , self-efficacy cwc , and flexibility cwc at T2. Finally, T2 work engagement was included as an observed variable equal to the mean score of the corresponding scale. As previously stated, gender, age, and organizational tenure were included as covariates at the individual level of the MSEM model.

At the team level, the latent measure of engaging leadership at T1 was assessed through the observed scores on the three dimensions of inspiring, strengthening, and connecting leadership. T2 team resources were modeled as a single latent factor indicated by the observed scores on performance feedback, trust in management, communication, and participation in decision-making. The observed mean score on T2 team effectiveness was modeled as the team level criterion variable.

At the individual level, the mediation was tested by considering path a , from T1 individual perceptions of engaging leadership (X) to T2 personal resources (M) and path b , from T2 personal resources to T2 work engagement (Y), controlling for X → Y. At the team level, the same procedure was applied considering path c , linking team perceptions of T1 engaging leadership (X) and T2 team resources (M) and path d , from T2 team resources to T2 team effectiveness (Y).

The individual and team-level perceptions of engaging leadership were assessed at T1. In contrast, the mediating variables (i.e., psychological capital and team resources), and the outcomes (i.e., work engagement and team effectiveness) were measured at T2.

Preliminary analysis

Before testing our hypotheses, a confirmatory factor analysis (CFA) was performed using the maximum likelihood method of estimation using the software package AMOS 21.0 [ 86 ]. This preliminary analysis was aimed at assessing redundancy between the constructs under investigation. For the team level, engaging leadership was included as a latent factor indicated by the observed team levels of inspiring, strengthening, and connecting leadership dimensions. The measured performance feedback levels indicated the latent team resources factor, trust in management, communication, and participation in decision-making. Team effectiveness, assessed as a criterion variable at the team level, was indicated by a single corresponding item. At the individual level, the group-mean centered scores on inspiring, strengthening, and connecting dimensions were considered indicators of the latent engaging leadership factor. Besides, optimism, resiliency, self-efficacy, and flexibility were included as indicators for the single personal resources latent factor; the observed average score on work engagement was used for assessing the corresponding latent variable. The model fit was assessed by considering the comparative fit index (CFI) and Tucker-Lewis Index (TLI) ≥ .95, Root-Mean-Square Error of Approximation (RMSEA) ≤ .06, and Standardized Root-Mean-Square Residual (SRMR) ≤ .08 [ 87 , 88 ]. According to these criteria, the hypothesized measurement model showed a good fit to the data, with χ 2 (91) = 465.09, CFI = .96, TLI = .95, RMSEA = .06, and SRMR = .03. Moreover, all indicators showed significant factor loadings on their respective latent factors ( p < .001) with λ values ranging from .51 to .95, thus exceeding the commonly accepted criterion of .50 [ 89 ]. Hence, these results support the assumption that the study variables were non-redundant and adequately distinct from each other.

Model testing

The means, standard deviations, correlations, and internal consistencies for all study variables are displayed in Table 2 . As expected, the constructs under investigation showed significant relationships in the hypothesized direction.

https://doi.org/10.1371/journal.pone.0269433.t002

The hypothesized MSEM showed a good fit to data: χ 2 (60) = 155.38, CFI = .97, TLI = .96, RMSEA = .04, SRMR = 0.03 (within teams) and .08 (between teams). As displayed in Fig 2 , at the individual level the three indicators of engaging leadership loaded significantly on their intended latent factor, with λ = .83 ( p = .000, 95% CI = [.79, .87]) for inspiring, λ = .77 ( p < .001, 95% CI = [.73, .81]) for strengthening, and λ = .81 ( p < .001, 95% CI = [.78, .85]) for connecting. Similarly, the standardized factor loadings for the indicators of personal resources were all significant as well: λ = .74 ( p < .001, 95% CI = [.68, .79]) for optimism, λ = .68 ( p < .001, 95% CI = [.63, .72]) for resiliency λ = .68 ( p < .001, 95% CI = [.62, .74]) for self-efficacy, and λ = .64 ( p < .001, 95% CI = [.59, .69]) for flexibility.

https://doi.org/10.1371/journal.pone.0269433.g002

The direct relationship between T1 engaging leadership and T2 work engagement was significant β = .16 ( p < .001, 95% CI = [.10, .22]). Moreover, results indicated that engaging leadership at T1 had a positive impact on personal resources at T2: γ = .27 ( p < .001, 95% CI = [.18, .37]). T2 personal resources, in turn, were positively associated with T2 work engagement: β = .55 ( p < .001, 95% CI = [.49, .62]). The estimated indirect effect of T1 engaging leadership on T2 work engagement via personal resources (i.e., a*b) was statistically significant: B (SE) = .19 (.04), p < .001, 95% CI [.11, .27]. Hence, personal resources (i.e., optimism, resiliency, self-efficacy, and flexibility) at T2 partially mediated the impact of T1 engaging leadership on employees’ engagement within work teams at T2. These findings provide partial support for Hypothesis 1 . Among the covariates included at the individual level, only gender and age showed a significant association with work engagement, with γ = -.10 ( p < .001, 95% CI = [-.15, -.05]) and γ = .10 ( p < .001, 95% CI = [.04, .16]), respectively.

At the team level, all factor loadings for the three indicators of engaging leadership on their corresponding latent variable were significant: λ = .95 ( p < .001, 95% CI = [.93, .99]) for inspiring, λ = .86 ( p < .001, 95% CI = [.80, .91]) for strengthening, and λ = .94 ( p < .001, 95% CI = [.90, .97]) for connecting. Additionally, the observed measure of each team resource loaded significantly on its intended latent variable: λ = .69 ( p < .001, 95% CI = [.56, .82]) for performance feedback, λ = .86 ( p < .001, 95% CI = [.78, .94]) for trust in management, λ = .89 ( p < .001, 95% CI = [.81, .97]) for communication, and λ = .71 ( p = .000, 95% CI = [.60, .82]) for participation in decision-making. Moreover, engaging leadership at T1 had a nonsignificant direct impact on team effectiveness at T2, with β = -.06 ( p = .641, 95% CI = [-.30, .19]). In contrast, team perception of engaging leadership at T1 had a positive impact on team resources at T2: γ = .59 ( p < .001, 95% CI = [.42, .75]). Team resources at T2 were, in turn, positively related to T2 team effectiveness, β = .38 ( p = .003, 95% CI = [.13, .62]). These results suggest full mediation and were supported by the estimation of the indirect effect of T1 engaging leadership on T2 team effectiveness via team resources at T2 (i.e., c*d): B (SE) = .18 (.07), p = .013, 95% CI [.04, .32]. Thus, Hypothesis 2 was fully supported.

Hence, in the current study team resources at T2 (i.e., performance feedback, trust in management, communication, and participation in decision-making) fully mediated the effect of T1 engaging leadership on T2 team effectiveness across different work teams. Moreover, T2 team resources (i.e., performance feedback, trust in management, team communication, and participation in decision-making) showed a significant cross-level effect on T2 individual team member’s level of engagement: β = .57 (p < .001, 195% CI = [.27, .87]). This result provided evidence for Hypothesis 3 .

The current study aimed to explore the role of individual and collective perceptions of engaging leadership in predicting team effectivity and work engagement. To this purpose, we developed a two-level research model using a two time-point design.

Main results

At the individual level, the obtained results suggest that psychological capital (i.e., the combination of self-efficacy, optimism, resiliency, and flexibility) partly mediated the longitudinal relationship between employees’ perceptions of engaging leadership and their levels of work engagement. In other words, team leaders perceived as inspiring, strengthening, and connecting could enhance their followers’ engagement directly and indirectly through an increase in psychological capital. Thus, engaging leaders could make their followers feel more optimistic, resilient, self-efficacious, and flexible. At the team level, a shared perception of engaging leadership was associated with a greater pool of team resources (i.e., performance feedback, trust in management, communication, and participation in decision-making), which contribute to define an open and supportive team climate that is conducive for employee growth and development. In their turn, these collective resources were positively related to the perceived effectiveness of work teams.

Hence, team resources at the team level fully mediated the relationship between engaging leadership and team effectiveness. That means that teams in which the leader is considered to be inspiring, strengthening, and connecting can draw upon more team resources, and could feel, in turn, more effective. Simultaneously, a significant cross-level mediation effect was found for team resources, meaning that they mediate the relationship between engaging leadership at team level and individual level work engagement. In other words, teams with engaging leaders are not only more effective at the team level, but they also report higher levels of work engagement among their members. These leaders create a team climate that fosters employee growth and development by providing performance feedback, installing trust, and stimulating communication and participation in decision-making.

Three different contributions.

Thus, three major conclusions can be drawn for the current study, which signifies its contribution to the literature. First, engaging leadership can be considered an individual-level construct (i.e., the perception of particular leadership behaviors by individual followers) and a collective, team-level construct (i.e., the shared perception of specific leadership behaviors among team members). As far as the latter is concerned, our results support the notion of an average leadership style (ALS) [ 47 ]; namely, that homogeneous leader-follower interactions exist within teams, but relationships of leaders with followers differ between teams.

Secondly, Individual-level engaging leadership predicts individual work engagement through increasing follower’s PsyCap. Previous research suggested a positive relationship between person-focused leadership styles and follower’s work engagement, albeit that virtually all studies were cross-sectional in nature (for an overview see [ 11 , 33 ]). Our study added longitudinal evidence for that relationship and hinted at an underlying psychological process by suggesting that psychological capital might play a mediating role. As such, the current study corroborates and extends a previous cross-sectional study that obtained similar results [ 8 ]. However, it should be noted that the present study used a slightly different operationalization of PsyCap as is usually employed [ 36 ]. In addition to the three core elements of optimism, resiliency, and self-efficacy, flexibility instead of hope was used as a constituting fourth element of PsyCap. The reason was that hope and optimism overlap both theoretically as well as empirically [ 35 ] and that flexibility–defined as the ability to readapt, divert from unsuccessful paths, and tackle unpredictable conditions that hinder employees’ goal attainment [ 8 ]–was deemed particularly relevant for public service agencies that are plagued by red tape. Our results indicate that engaging leaders strengthen followers’ sense of proficiency when developing a task-specific skill to reach challenging objectives (i.e., self-efficacy). They also encourage a favorable appraisal of the prevailing conditions and future goal achievement (i.e., optimism).

Furthermore, they enhance subordinates’ abilities to recover from failures and move beyond setbacks effectively (i.e., resiliency) through supporting an increased aptitude for adaption to unfamiliar work circumstances (i.e., flexibility). These results corroborate the assumption that leaders who inspire, strengthen, and connect their followers provide a stimulating work environment that enhances employees’ personal resources. In their turn, elevated levels of PsyCap mobilize employees’ energy and intrinsic motivation to perform, expressed by a high level of work engagement. This result concurs with previous evidence that PsyCap can be framed as a critical component of the motivational process of the JD-R model, namely as a mediator of the relationship between contextual resources (i.e., engaging leadership) and work engagement [ 46 ]. However, this mediation was only partial because a direct effect of engaging leadership on follower’s work engagement was also observed in the current study. This evidence is not surprising since previous research showed that other mediating factors (which were not included in the present study) played a role in explaining the relationship between leadership and work engagement. Among them, innovative work behaviors, meaningful work, role clarity, positive emotions, identification with the organization, and psychological ownership [ 11 ]. Thus, increasing their follower’s PsyCap is not the whole story as far as the impact of engaging leadership is concerned. It is likely that engaging leaders also impact these alternative mediating factors. If this is the case, this might explain why the additional variance in follower’s work engagement is explained by engaging leadership, as indicated by the direct effect.

Thirdly, team-level engaging leadership predicts work engagement of individual team members and team effectiveness through increasing team resources. An earlier cross-sectional study found that engaging leadership, as perceived by their followers, showed an indirect, positive effect on their work engagement level through an increase in job resources [ 7 ]. However, in that study, engaging leadership and job resources, including performance feedback, trust in management, communication, and participation in decision-making, were assessed at the individual and not at the aggregated team level. This means that the current study corroborates previous findings at the aggregated team level, using a longitudinal design. It is important to note that employees’ level of work engagement not only depends on individual-level processes (through the increase in PsyCap) but also on collective processes (trough the rise in team resources). Finally, our findings concur with research on team climate, showing that leaders who endorse supportive relations between team members and create an open, empowering team climate enable employees to succeed [ 33 ]. Simultaneously, a team climate like that is also likely to foster personal growth and development, which, in turn, translates into greater work engagement [ 63 ].

Practical implications

Our study shows that engaging leadership matters, and therefore organizations are well-advised to stimulate their managers to lead by the principles of engaging leadership. To that end, organizations may implement leadership development programs [ 90 ], leadership coaching [ 91 ], or leadership workshops [ 92 ]. Previous research has shown that leadership behaviors are malleable and subject to change using professional training [ 93 – 95 ]. Furthermore, leaders may want to establish and promote an open and trusting team climate in which employees feel free to express their needs and preferences [ 96 , 97 ].

Accordingly, our study shows that this climate is conducive not only for work engagement but also for team effectiveness. Finally, our results also suggest that psychological capital is positively associated with work engagement, so that it would make sense to increase this personal resource, mainly because PsyCap is state-like and open to development through instructional programs [ 45 ]. For instance, a short PsyCap Intervention (PCI) has been developed by Luthans and colleagues, which is also available as a web-based version for employees [ 98 ]. PCI focuses on: (a) acquiring and modifying self–efficacy beliefs; (b) developing realistic, constructive, and accurate beliefs; (c) designing goals, pathway generation, and strategies for overcoming obstacles; and (d) identifying risk factors, and positively influencing processes.

Strengths, limitations, and directions for future research

A significant strength of the current study is its design that combines a multilevel investigation of engaging leadership with mediating processes at the individual and team levels. This is in line with the claim that leadership research suffers from a lack of theoretical and empirical differentiation between levels of analysis [ 99 ]. However, leadership is an inherently multilevel construct in nature [ 9 ]. Although the current findings shed light on the role of the emergent construct of engaging leadership, both regarding individuals and teams, an exciting venue for future research involves exploring its predictive validity in comparison with traditional leadership models. This concurrent validation would adhere to the recommendations accompanying the introduction of new leadership constructs in the face of the risk of construct proliferation [ 16 ].

A further strength of the current study is its large sample size, including 1,048 employees nested within 90 work teams. Moreover, data were collected at two time points with a one-year time lag that was considered long enough for the effects of engaging leadership to occur. In contrast with widespread cross-sectional studies that sometimes draw unjustified conclusions on the corollaries of leadership [ 100 ], the current research relied on a longitudinal design to better understand the consequences of engaging leadership at the individual and team level of analysis. According to our results, engaging leadership indeed shows a positive effect across time on outcomes at the individual (i.e., work engagement) and team level (i.e., team effectiveness).

Along with its strengths, the current study also has some limitations that should be acknowledged. The main weakness of the current study lies in the homogeneity of the sample, which consisted of employees working in a Dutch public service agency. This specific work setting prevents us from generalizing the findings of our research with other occupational groups. However, focusing on an organization where most activities are conducted in teams permits independent but simultaneous assessment of the impact of (engaging) leadership on the perceived pool of resources among teams and workers, as suggested by current trends in leadership literature [ 101 , 102 ].

Furthermore, the collection of data at different time points overcomes the inherent weakness of a cross-sectional design, yet a design including at least three data waves would have provided superior support for the hypothesized mediated relationships. Based on within-group diary studies [ 103 , 104 ], it can, on the one hand, be argued that leadership might impact the team and personal resources within a much shorter time frame. On the other hand, work engagement represents a persistent psychological state that is not susceptible to sudden changes in the short term [ 1 ]. Thus, the chosen one-year time lag can be considered reasonable for a between-group study to detect the impact of engaging leadership accurately. This impact needs some time to unfold. An additional limitation of this study entails measuring individual and team resources with only a few items. Nevertheless, all scales had an internal consistency value that met the threshold of .65 [ 105 ] with an average Cronbach’s alpha value equal to .81.

Concluding remark

Despite the novelty of the construct, the emerging research on engaging leadership suggests the potential value of a theoretically sound leadership model that could foster followers’ engagement. While earlier findings showed that engaging leadership is positively associated with the employee’s level of engagement [ 7 , 8 ], the current study suggested that engaging leadership could predict work engagement and team effectiveness. More specifically, being exposed to a leader who inspires, strengthens and connects team members may foster a shared perception of greater availability of team resources (i.e., performance feedback, trust in management, communication, and participation in decision-making), as well as greater psychological capital (i.e., self-efficacy, optimism, resilience, and flexibility). Hence, engaging leadership could play a significant role in the processes leading to work engagement at both the team and the individual levels.

Supporting information

https://doi.org/10.1371/journal.pone.0269433.s001

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SYSTEMATIC REVIEW article

The role of leadership in a digitalized world: a review.

• 1 Department of Management, Ca' Foscari University, Venice, Italy
• 2 Department of Business and Management, LUISS Guido Carli University, Rome, Italy

Digital technology has changed organizations in an irreversible way. Like the movable type printing accelerated the evolution of our history, digitalization is shaping organizations, work environment and processes, creating new challenges leaders have to face. Social science scholars have been trying to understand this multifaceted phenomenon, however, findings have accumulated in a fragmented and dispersed fashion across different disciplines, and do not seem to converge within a clear picture. To overcome this shortcoming in the literature and foster clarity and alignment in the academic debate, this paper provides a comprehensive analysis of the contribution of studies on leadership and digitalization, identifying patterns of thought and findings across various social science disciplines, such as management and psychology. It clarifies key definitions and ideas, highlighting the main theories and findings drawn by scholars. Further, it identifies categories that group papers according to the macro level of analysis (e-leadership and organization, digital tools, ethical issues, and social movements), and micro level of analysis (the role of C-level managers, leader's skills in the digital age, practices for leading virtual teams). Main findings show leaders are key actors in the development of a digital culture: they need to create relationships with multiple and scattered stakeholders, and focus on enabling collaborative processes in complex settings, while attending to pressing ethical concerns. With this research, we contribute to advance theoretically the debate about digital transformation and leadership, offering an extensive and systematic review, and identifying key future research opportunities to advance knowledge in this field.

Introduction

The findings of the latest Eurobarometer survey show the majority of respondents think digitalization has a positive impact on the economy (75 percent), quality of life (67 percent), and society (64 percent) ( European Commission, 2017 ). Indeed, people's daily lives and businesses have been highly transformed by digital technologies in the last years. Digitalization allowed to connect more than 8 billion devices worldwide ( World Economic Forum, 2018 ), modified information value and management, and started to change the nature of organizations, their boundaries, work processes, and relationships ( Davenport and Harris, 2007 ; Lorenz et al., 2015 ; Vidgen et al., 2017 ).

Digital transformation refers to the adoption of a portfolio of technologies that, at varying degrees, have been employed by the majority of firms: Internet (IoT), digital platforms, social media, Artificial Intelligence (AI), Machine Learning (ML), and Big Data ( Harvard Business Review Analytic Services, 2017 ). These tools and instruments are “rapidly becoming as infrastructural as electricity” ( Cascio and Montealegre, 2016 , p. 350). At macro levels, the shift toward different technologies is setting the agenda for new mechanisms of competition, industry structures, work systems, and relations to emerge. At the micro level, the digitalization has impacted on business dynamics, processes, routines, and skills ( Cascio and Montealegre, 2016 ).

Across different sectors and regardless of organization size, companies are converting their workplaces into digital workplaces. As observed by Haddud and McAllen (2018) , many jobs now involve extensive use of technology, and require the ability to exploit it at a fast pace. Yet, digitalization is being perceived both as a global job destroyer and creator, driving a profound transformation of job requirements. In result, leaders need to invest in upskilling employees, in an effort to support and motivate them in the face of steep learning curves and highly cognitively demanding challenges. Moreover, increased connectivity and information sharing is contributing to breaking hierarchies, functions and organizational boundaries, ultimately leading to the morphing of task-based into more project-based activities, wherein employees are required to directly participate in the creation of new added value. As such, the leadership role has become vital to capture the real value of digitalization, notably by managing and retaining talent via better reaching for, connecting and engaging with employees ( Harvard Business Review Analytic Services, 2017 ; World Economic Forum, 2018 ). However, leaders need to be held accountable for addressing new ethical concerns arising from the dark side of digital transformation. For instance, regarding the exploitation of digitalization processes to inflict information overload onto employees, or to further blur the lines between one's work and personal life.

In the last few decades, leadership scholars have been trying to monitor the effects of digitalization processes. Part of the academic debate has been focused on the role of leaders' ability to integrate the digital transformation into their companies and, at the same time, inspire employees to embrace the change, which is often perceived as a threat to the current status quo ( Gardner et al., 2010 ; Kirkland, 2014 ). To bring clarity to this debate, the construct of e-leader has been introduced to describe a new profile of leaders who constantly interact with technology ( Avolio et al., 2000 ; see also Avolio et al., 2014 for a review). Accordingly, e-leadership is defined as a “social influence process mediated by Advanced Information Technology (AIT) to produce a change in attitudes, feelings, thinking, behavior, and/or performance with individuals, groups, and/or organizations” ( Avolio et al., 2000 , p. 617).

Despite the increasing interest in discussing the relationship between digital technology and leadership, contributions have accumulated in a fragmented fashion across various disciplines. This fragmentation has made scholars struggle “to detect larger patterns of change resulting from the digital transformation” ( Schwarzmüller et al., 2018 , p. 114). It also suggests that scholars have relied on multiple theoretical models to explain the phenomenon. Indeed, if, on one hand, it is clear that organizations are changing due to technological improvements, on the other hand, the way in which the transformation is occurring remains under debate. Furthermore, due to the fast-changing development and implementation of digital technology, there is a need to continuously update and consider the latest contributions to the topic.

This article addresses the aforementioned issues by offering a systematization of the literature on digitalization and leadership that has been accumulating across different disciplines, while adopting an interdisciplinary approach and providing a systematization of articles from different fields that analyze digitalization and leadership. Specifically, the present article reviews the literature on how the advent of digital technologies has changed leaders and leadership roles. Moreover, it structures and summarizes the literature, considering both theoretical frameworks and empirical findings, and fostering the understanding of both the content of the debate and its practical underpinnings. Lastly, reflecting on the findings of this review, we offer suggestions for future directions of research.

The present review draws on the following boundary conditions. First, we relied on a broad definition of leadership, in which the leader is understood as a person who guides a group of people, an organization, or empowers their transformational processes. Second, we excluded studies referring to market or industry leaders, in which the leader is represented by an organization. Third, we considered studies that clearly referred to a digital or technological transformation. Fourth, we did not include studies in which there was not a clear link between information technology and leadership (e.g., city leaders protecting the physical and digital infrastructures of urban economies regarding climate change). Therefore, our review was guided by the following research questions: (i) What are the main theoretical frameworks guiding the academic discussion on digital transformation and leadership? (ii) What are the main categories emerging from the contributions that address the relationship between digital transformation and leadership? And (iii) Which are the main future directions of research that scholars should consider?

This paper is structured as follows: First, it describes the methodology used; Second, it proposes a classification of findings based on theoretical frameworks and content. Finally, it describes implications of our findings for both research and practice, and proposes directions for future research.

Research Design

The aim of this paper is to investigate how the debate on digital transformation and leadership has evolved in recent years, to identify key theories and findings, and to propose potential future directions of research. To answer our research questions, we use a mixed method approach, that involves both quantitative research through standard databases and qualitative coding ( Crossan and Apaydin, 2010 ; Peteraf et al., 2013 ; Zupic and Čater, 2015 ).

Data Collection

We collected papers from the Scopus database, one of the most widely used sources of scientific literature ( Zupic and Čater, 2015 ). We also checked Web of Science and Ebsco databases in order to avoid missing articles. Because we did not find any relevant distinction between these databases regarding this topic, we chose to use Scopus only. We firstly accessed the database on September 1st, 2018.

Since our research questions concerned the academic discussion on digital transformation and leadership, the scope of our search was limited to academic articles (not only from peer-reviewed journals but also from unpublished sources, such as unpublished manuscripts). Non-academic books and other publications were outside the scope of our study and were therefore excluded from our search. Our initial search was undertaken using the basic keywords: leader * AND digital * OR e-leader * . The keywords were used as a selection criterion for the topic (title, keywords, or abstract). We searched peer-reviewed papers published in English, in journals focusing on the following subject areas: Business, Management, and Accounting; Psychology; and Social Science, without any additional selection restrictions. We decided to scan articles published in other areas than Business and Management since the topic is covered by several disciplines. These criteria resulted in an initial sample of 790 articles. The following figure ( Figure 1 ) shows how the debate grew since 2000, and significantly expanded since 2015.

Figure 1 . Growth of articles on leadership and digitalization.

In order to avoid a potential publication bias ( O'Boyle et al., 2017 ), and to scan recent studies that might not have had the time to go through the entire publication process, we performed a search within conference proceedings since 2015, using the same aforementioned criteria. The initial sample comprised 113 articles.

The second step within our data collection process involved a qualitative selection of articles. We first considered publications with at least one citation among those published before 2013, seen that the number of citations is a common criterion of scientific rigor and impact in academia ( Garfield, 1979 , 2004 ; Peteraf et al., 2013 ). As citation-based methods may discriminate against recent publications ( Crossan and Apaydin, 2010 ), we kept all papers published after 2013. Based on the assumption that top journals publish high quality papers, we discarded studies that were not included within the first 200 journals appearing in the Scimago list within the Management and Business, Social Science, and Psychology areas. Then, both peer-reviewed articles and conference proceedings were filtered based on the assessment of whether the abstracts were in alignment with the topic and the boundary conditions. Articles were selected based on the following criteria: (i) the leader was a person who guides a group, organization, or empowers their transformational processes; (ii) there was a clear reference to digital or technological transformation; (iii) there was a clear link between information technology and leadership. Articles that focused on either digital transformation or leadership only were excluded, as well as papers that were outside our boundary conditions, such as studies on industry leaders using digital platforms. Figure 2 summarizes the selection criteria and the boundary conditions used to scan the articles. The search criteria resulted in a final dataset of 54 studies.

Figure 2 . Search strategy and selection criteria.

Data Analysis and Qualitative Coding

To attain a “systematic, transparent and reproducible review process” ( Zupic and Čater, 2015 , p. 429), and identify research streams and seminal works, we first performed a bibliometric analysis of the initial dataset of 790 articles. In order to map the origin and evolution of the academic debate on digital transformation and leadership, a systematic coding analysis was conducted on the entire set of articles. Then, the iterative reading and discussion of the final dataset of articles highlighted the following emerging categories that guided our analysis ( Strauss and Corbin, 1998 ): (i) theoretical or empirical papers; (ii) research methodology; (iii) level of analysis (micro and macro); (iv) definition of leadership and digitalization; (v) main themes or objectives of the article; (v) main underlying theories; (vi) field of study (e.g., Management and Planning, Economics and Business, Psychology and so forth). Based on this coding scheme, the three authors independently read and coded all articles. Subsequently, they discussed their coding attribution until an agreement on the final coding of each article was reached.

Dataset Description

The final database comprises 54 articles, of which 42 are peer-reviewed papers published by 33 journals, while the remaining 12 papers are conference proceedings (see Table 1 ).

Table 1 . Dataset citations, source, level of analysis and empirical/theoretical approach.

Regarding the peer reviewed articles in our dataset, most of them stem from Economic, Business and Management (22 articles), and Information and Communication Sciences (10 articles). Only three studies come from the Psychology discipline. As for the sources wherein these articles are published, we count two journals that specifically address the leadership field, such as “The Leadership Quarterly” and “Strategy and Leadership”, whereas the remaining 31 other journals are spread across areas such as Economics, Business and Management, Information and Communication Sciences, Psychology, Educational, Heath and Political Sciences. The novelty of the topic and the breadth of journals in which it is published confirms that the field of digital transformation and leadership has garnered interest from several difference disciplines. Such fragmentation of the literature and the different perspectives it has enabled, justifies the need for systematization and alignment of future research.

As for the conference proceedings, half of the articles come from international and peer-reviewed conferences advancing the debate of digital transformation in business, such as the International Conference on Electronic Business, the Scandinavian Conference on Information Systems, the IEEE Conference on e-Learning, e-Management and e-Services.

Among the top five most cited articles in our sample, three come from journals that specifically relate to Human Resources: “Leadership Quarterly” and “Organizational Behavior and Human Decision Processes.” In these articles the authors focus on the characteristics of digital leaders in terms of roles and behaviors, stressing the idea that technology is deeply changing the way in which leaders conceive communication and cope with their followers ( Avolio et al., 2000 , 2014 ; Horner-Long and Schoenberg, 2002 ; Hambley et al., 2007 ).

As shown in Figure 1 , the early 2000s witnessed an initial interest in the topic, when pioneering work began to consider the changes that digitalization brings in the area of leadership and how the concept and practice of leadership are affected by new technologies ( Avolio et al., 2000 ; Coutu, 2000 ). However, it has been mostly over the last decade that the topic garnered seesawing attention. It is plausible to assert that the much stronger impact that technological development has had within organizations recently, and the expectation that technological evolution will be even more disruptive in the near future, has accelerated the interest on the topic. Indeed, while all peer-reviewed articles in our sample are from 2000 on, 60 percent were published after 2014. As for conference proceedings, we only considered the contributions presented after 2015 in order to understand how the debate has been developing in recent years.

Regarding the level of analysis (micro vs. macro), the majority of contributions within our sample are at the micro-level (30 articles), while 24 adopt a macro perspective. Within the latter, it is interesting to notice that a considerable number of articles do not pertain to the management field. As to the type of contribution, the majority of articles in our sample (37) are empirical studies, while only a few articles are conceptual. This imbalance reveals there is still a lack of theorization about the impact of technology on leadership. Nevertheless, in the next session we systematize the main theoretical frameworks that have been used to address this topic.

Main Theoretical Frameworks

The analysis of the theoretical content of our dataset highlighted that only a small set of studies explicitly refers to the extant theoretical frameworks describing the impact of digital transformation on leadership. Advanced information technologies theory ( Huber, 1990 ), according to which the adoption of information technologies influences changes in organization structure, information use, and decision-making processes, is used as common ground. Scholars agree on the high impact of technology in leadership behavior and identify Information Technologies (IT) developments as a driver for creating disruptive changes in businesses and in leadership roles across different organizational functions ( Bartol and Liu, 2002 ; Geoffrion, 2002 ; Weiner et al., 2015 ; Sousa and Rocha, 2018 ). These changes are so dramatic that scholars started to adopt a new terminology to characterize the e-world, e-business and e-organizations ( Horner-Long and Schoenberg, 2002 ). Recent studies have been discussing the notion of digital ubiquity ( Gerth and Peppard, 2016 ; Schwarzmüller et al., 2018 ), describing the pervasive proliferation of technology ( Roman et al., 2018 ). With this term, scholars refer to a context in which technological equipment is prevalent and constantly interacts with humans. It describes a scenario in which “computer sensors (such as radio frequency identification tags, wearable technology, smart watches) and other equipment (tablets, mobile devices) are unified with various objects, people, information, and computers as well as the physical environment” ( Cascio and Montealegre, 2016 , p. 350).

In terms of leadership theoretical frameworks, scholars seem to turn to a plethora of different theories and definitions. Horner-Long and Schoenberg (2002) contrapose two main theoretical approaches: universal theories and contingency theories. The former supports the view that leaders differ from other individuals due to a generic set of leadership traits and behaviors which can be applied to all organizations and business environments (see for example Lord et al., 1986 ; Kirkpatrick and Locke, 1991 ). The latter argues that, in order to be effective, leadership should adopt a style and behaviors that match the context (e.g., Tannenbaum and Schmidt, 1973 ; Goleman, 2000 ). The authors empirically explore leadership profile characteristics, comparing e-business leaders and leaders from traditional bricks and mortar organizations. Results do not clearly support any of the two approaches. They suggest that in both contexts most of leadership characteristics are equally valued. However, certain characteristics distinguish e-world leaders from leaders in traditional industries. While Horner-Long and Schoenberg (2002) analyze leader profile differences across industries, Richardson and Sterrett (2018) adopt a longitudinal design, exploring how digital innovations influenced the role of technology-savvy K-12 district leaders across time. They base their work on a unified model of effective leadership practices that influence learning ( Hitt and Tucker, 2016 ). Although the leadership practice model is maintained across time, the authors recognize some shifts in the way those practices are implemented.

Only Obschonka et al. (2017) specifically adopt a universal perspective, drawing from trait approach theory ( Stogdill, 1974 ). By analyzing the language used to communicate via Twitter, the authors identify the personality characteristics that distinguish the most successful managers and entrepreneurs.

Heinz et al. (2006) follow a contingency approach, emphasizing the need to take into account the context and consider situational aspects that can influence leadership and cooperation practices.

Most studies in our sample assume that the change in context due to technological advancement may influence leadership. According to Lu et al. (2014 , p. 55), it cannot be assumed that “leadership skills identified in offline context should be transferred to virtual leadership without any adjustment.”

However, some authors make this assumption tacitly (e.g., Schwarzmüller et al., 2018 ), without explicitly addressing any related theoretical framework. Bolden and O'Regan (2016 , p. 439) report that “there is no one approach to leadership,” since leadership is context specific and must to be adapted to the needs of the day. Similarly, Lu et al. (2014) maintain that effective leadership behaviors are determined by the situation in which leadership is developed.

To address the diversity of situations and contexts, Jawadi et al. (2013) overcome the limits of a pure contingency approach and embrace complexity, adopting the framework of leadership behavioral complexity theory ( Denison et al., 1995 ). In a context characterized by complex and unanticipated demands, a leader needs to develop a behavioral repertoire that allows dealing with contradictory and paradoxical situations ( Denison et al., 1995 ). As contingencies are evolving so rapidly as to be considered in a state of flux, an effective leader needs to be able to conceive and perform multiple behaviors and roles.

Avolio et al. (2000 , 2014 ), make a step forward in defining the role of context.

Similarly to Bartol and Liu (2002) , the authors adopt a structurational perspective (Adaptive Structure Theory) (AST; DeSanctis and Poole, 1994 ) as the main theoretical framework. According to their point of view, digital technologies and leadership reciprocally influence and change each other in a recursive relationship. In their perspective, not only technology influences leadership, but also leaders appropriate technology, and it is through the interaction between information technology and organizational structures that the effect of technology on individuals, groups, and organizations emerges. In this view, the context is not only shaping and shaped by leaders; it is part and parcel of the construct of e-leadership itself. Avolio et al. (2000 , 2014 ) remarkably paved the way for the conceptualization of e-leadership, which has since been adopted by many other authors to inform their studies ( Avolio et al., 2000 ; Lynn Pulley and Sessa, 2001 ; Roman et al., 2018 ).

Similarly, Orlikowski (1992) develop a Structurational Model of Technology, whereby technology influences the context in which actors perform but is also designed and socially constructed by its users ( Van Outvorst et al., 2017 ).

Looking at leaders' relationships with their teams, scholars refer to the following main theories: transactional leadership theory, transformational leadership theory ( Burns, 1978 ; Bass, 1981 , 1985 ), and leader-member exchange theory (LMX; Graen and Scandura, 1987 ). Transactional and transformational leadership are among the most influential and discussed behavioral leadership theories of the last decade ( Diaz-Saenz, 2011 ). They distinguish transformational leaders, who focus on motivating and inspiring followers to perform above expectations, from transactional leaders, who perceive the relationship with followers as an exchange process, in which follower compliance is gained through contingent reinforcement and rewards ( Bass, 1985 ). Previous studies reveal that leadership styles may influence virtual team interactions and performance (e.g., Sosik et al., 1997 ; Sosik et al., 1998 ; Kahai and Avolio, 2006 ). As such, Hambley et al. (2007) explore the effects of transactional and transformational leadership on team interactions and outcomes, comparing teams interactions across different communication media: face-to-face, desktop videoconference, or text-based chat. Likewise, Lu et al. (2014) compare virtual and offline interactions, drawing on transactional and transformational leadership theories to understand whether leadership styles of individuals playing in Massive Multiplayer Online Games (MMOGs) can be associated to their leadership status in offline contexts. However, this association is found to be significant only with offline leadership roles in voluntary organizations, not in companies. Results in Hambley et al. (2007) also show that the association between leadership style and team interaction and performance does not depend on the communication medium being used.

While transactional and transformational leadership theories adopt a behavioral perspective in which the focal point is the leader behavior with regards to the follower, leader-member exchange theory (LMX) introduces a dyadic point of view. Leader-member exchange theory focuses on the nature and quality of the relationship between leaders and their team members. The quality of this relationship, which is characterized by trust, respect, and mutual obligation, is thought to predict individual, group and organizational outcomes ( Gerstner and Day, 1997 ). Jawadi et al. (2013) use the concept of leader-member exchange as a dependent variable, exploring how multiple leadership roles influence cooperative and collaborative relationships in virtual teams. Bartol and Liu (2002) build on leader-member exchange theory to suggest policies and practices HRM professionals can use to implement IT-information sharing and positively influence employee perceptions.

The democratization of informational power gave momentum to distributed power dynamics. Moving beyond the centrality of the sole vertical leader, the shared leadership approach emphasizes the role of teams as potential source of leadership ( Pearce, 2004 ; Ensley et al., 2006 ; Pearce et al., 2009 ). Shared leadership is “a manifestation of fully developed empowerment in teams” ( Pearce, 2004 , p. 48) in which leadership behaviors that “guide, structure, or facilitate the group may be performed by more than one individual, and different individuals may perform the same leadership behaviors at different times” ( Carte et al., 2006 : p. 325).

Acknowledging the relevance of increased connectivity in the digital era, some studies underscore the importance to take into account a network perspective. Lynn Pulley and Sessa (2001) contrapose the industrial economy to the current networked economy. Bartol and Liu (2002) define networked organizations as those organizations characterized by three major types of connectivity: inter-organizational (also known as boundaryless; Nohria and Berkley, 1994 ), intra-organizational, and extra-organizational. Kodama (2007) views the organization as the integration of different types of networked strategic communities, wherein knowledge is shared and assessed. Sullivan et al. (2015) use a network representation to depict shared leadership. Gordon (2007) explores how the network is embedded in the concept of web that is currently accepted.

The Macro Perspective of Analysis: Main Categories

The studies on digitalization and leadership that adopt a macro-perspective of analysis can be classified in four different categories, according to whether they focus on: (1) The relationship between e-leaders and organizations; (2) How leaders adopt technology to solve complex organizational problems; (3) The impact of digital technologies on ethical leadership; or (4) The leader's use of digital technologies to influence social movements.

The Relationship Between E-Leaders and Organizations

The studies within our sample that take a macro or organizational-level approach are considerably less than those which investigate the micro dynamics occurring within organizations. A summary is shown in Table 2 . This imbalance is probably due to the relatively greater urgency and challenge to understand the role of leaders and leadership in guiding and implementing the digitalization process within organizations, rather than what new forms of organizations are emerging as a result of the digital transformation. As observed by a recent Harvard Business Review Analytic Services report (2017 ), leaders have increasingly become the key players in driving positive results from the investments on digital tools and technologies.

Table 2 . Main categories summary.

In the last few years, scholars have begun to adopt the construct of e-leader in order to specifically refer to those leaders who have initiated a massive process of digitalization in their organizations. Despite the call to understand how organizations and e-leaders are intertwined, few studies provide an empirical explanation of the new organizational configurations emerging from the interaction between technology and the human/social system. Berman and Korsten (2014) is one among the few. By surveying a large sample of CEOs, running companies of different sizes and across 64 countries and 18 industries, the authors showed that outperforming organizations had leaders that created open, connected and highly collaborative organizational cultures. The authors suggest future leaders should base their organizations on three pillars: (1) Assuring a highly connected and open working environment at any hierarchical levels and units in organizations; (2) Engaging customers by gathering knowledge about the whole person; and (3) Establishing more integrated and networked relationships with partners and competitors ( Berman and Korsten, 2014 ). They posit these three pillars transform the organizations at all levels. This implies organizations are becoming boundaryless, at both the internal and external levels. Further, the organizational structure is no longer a static feature, but an ongoing process ( Van Outvorst et al., 2017 ). While a shift toward an ecological perspective— one where organizations' boundaries are loose and permeable—requires higher coordination, collaboration and individual responsibility, it also enhances innovative capabilities ( Lynn Pulley and Sessa, 2001 ). According to Kodama (2007) , managers at any level can foster innovation if they go beyond the formal organization, to create real or virtual networks among internal and/or external communities of practice. These communities of practice enable a more agile response to change, promoting the free-flow of information and breaking down information silos ( Petrucci and Rivera, 2018 ), thereby empowering both managers and employees to integrate, transform and stimulate knowledge that fosters innovation. This way, information and communication technology enables the creation of shared information pools wherein diverse staff across the organization contribute to a collaborative and dynamic process of idea generation. Moreover, such co-generation of ideas and knowledge cultivates stronger relationships between disparate organizational units, further facilitating open innovation processes ( Henttonen et al., 2012 ).

In sum, by breaking the organizational boundaries within and between internal and external stakeholders, the traditional leader-centered information and decision-making process is giving way to novel processes that democratize access to information and share decision power among all parties involved.

Digital Tools and Organizations: How Technology Enhances the Optimization of Complex Organizational Environments

Although most papers adopting a macro perspective reflect on the novel structures of organizations, they tend to underestimate the effect of digital transformation on organizational processes. That is, however, not the case with Weiner et al. (2015) , who discuss how the effective achievement of operational goals relies on the fit between strategic planning and information technology, particularly in operationally complex organizations, such as hospitals. Their empirical study shows that digital tools could highly contribute in the planning and monitoring of internal processes, increasing the transparency and accountability across all levels of management, and engaging customers' trust. For instance, the intelligent use of data through sophisticated digital tools, allowed hospitals administrators to lead improvements in decision-making processes and service quality by enhancing the usage of traditional management tools, such as key performance indicators (KPIs), and storage of critical data, namely on infections and diseases. Notably, this study offers empirical evidence on the need to adopt digital technology to develop efficient internal organizational processes and guarantee high quality service to customers. In another empirical study conducted in a hospital, the authors confirmed that the use of digital tools helped leaders solve complex issues related to personnel and operational costs. Similarly to the previous study aforementioned, data were used to re-design the entire organization with the aim of optimizing the efficiency in the use of both facilities and processes ( Morgareidge et al., 2014 ).

Leaders are responsible for verifying the suitability of technological tools being adopted or implemented in relation to the organizational needs and objectives. Moreover, while we acknowledge that digital technologies hold the potential for improving the efficiency of organizational processes, we contend that they need to be internalized and integrated within employees' routine tasks in order for organizations to minimize attritions from their adoption and fully capture its benefits.

Organizations and Ethics

Ethics in leadership roles has been an issue of concern to scholars especially since the emergence of the transformational leadership paradigm ( Burns, 1978 ; Bass and Avolio, 1993 ). In general, ethical leadership is defined as “the demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through two-way communication, reinforcement, and decision-making” ( Brown et al., 2005 , p. 120). With the advent of digital transformation and the massive use of data, scholars have begun to call into question the integrity of leaders. Indeed, the use of data and technologies exposes leaders to new dilemmas, which nature is intertwined with ethical concerns. For instance, the use of sensitive data is driving leaders' increased concerns about privacy protection and controlling mechanisms in the workplace ( Kidwell and Sprague, 2009 ). Electronic surveillance (ES) is a way to collect data about employees and their behavior, so as to improve productivity and monitor behaviors in the workplace ( Kidwell and Sprague, 2009 ). ES rules vary across countries and cultures. For instance, the US Supreme Court of Justice obliged employers to adopt ES to monitor employees in order to prevent sexual harassment ( Kidwell and Sprague, 2009 ). Notwithstanding, Europe has been more concerned with individual privacy. Notably, in 1986, the Organization for Economic Cooperation and Development (OECD) approved a declaration on social aspects of technological change, whereby member states “were concerned that employers and unions ensure that workers' privacy be protected when technological change occurs” ( Kidwell and Sprague, 2009 , p. 199). Perhaps the boldest manifestation of this concern is the recently adopted EU General Data Protection Regulation (GDPR), which has just come into force the past May 25th, 2019.

In this scenario, leaders are required to set clear guidelines and practices that lie within national and international data security policies. In particular, they need to monitor the use of personal sensitive data, if not for the ethical concern per se , because if otherwise caught in unlawful data practices, their organizations' reputation, trustworthiness, and brand image could suffer irreparable damage (e.g., the recent scandal of Cambridge Analytica about an inappropriate use of personal data, has affected the reputation of all organizations involved) ( Gheni et al., 2016 ; Jones, 2017 ). Leaders also need to set clear expectations for employees and act as role models for all members of the organization in order to clarify what ethical behavior regarding personal sensitive data looks like. This is especially true for organizations that strongly rely on virtual communications, as these tend to stimulate more aggressive and unethical behavior, due to their lack of face-to-face interactions ( Gheni et al., 2016 ). Leaders, therefore, have a pivotal role in weeding out potential unethical behaviors from their organizations.

Finally, an emerging topic in leadership concerns the unlawful appropriation of technology from private and public organizations. Specifically, it refers to situations wherein technology is used for purposes other than those it had originally been intended ( Jones, 2017 ). For instance, improper use of technology may result in unauthorized access to data and lead to cyber security breaches ( Jones, 2017 ).

Despite the interdisciplinary relevance of ethics, the debate of ethical concerns within e-leadership seems to be currently confined to the literature on governance and information technology. Yet, there is room for more theoretical and empirical discussion about how ethics is affecting power relations, surveillance, safety perceptions in the workplace, and human resource processes.

Leadership and Digital Tools: Insights From Social Movement Studies

A complementary perspective of leadership and digitalization is provided by several recent studies that analyze social and political events, in particular grassroots movements such as the Occupy and Tea Party ( Agarwal et al., 2014 ), the Umbrella Movement in China ( Lee and Man Chan, 2016 ) and the political tensions in Russia ( Toepfl, 2018 ). These contributions share the notion of leader as someone who directs collective action and creates collective identities ( Morris and Staggenborg, 2004 ). These studies, mainly rooted in communication and political sciences, are certainly relevant to our review as they shed light on the social nature of leadership in the new digital era.

These studies focus on how social media and digital tools are disrupting traditional forms of leadership, altering the structure, norms and hierarchy of organizations, and creating new practices to manage and sustain consensus ( David and Baden, 2018 ). New forms of leadership are for instance defined as horizontal and leaderless ( Castells, 2012 ; Bennett and Segerberg, 2013 ). The horizontality defines movements and groups in which authority is dismissed, whereas leaderless points to the lack of power stratification among the participants ( Sitrin, 2006 ; Gerbaudo, 2017 ).

In a similar vein, recent studies looking at the use of digital tools by participants in social movements, observe how power struggles were changed by new information and communication technologies (ICTs): “ICTs have transformed the power dynamics of social movement politics by challenging traditional forms of [social] organizations” ( Agarwal et al., 2014 , p. 327).

The single case study of the ultra-orthodox community illustrates for instance how authoritarian leadership can be broken down by digital tools and social media ( David and Baden, 2018 ). When the leadership of a closed and conservative religious community is questioned in social media, that creates a new space to renegotiate the community's boundaries and modify its power dynamics: “the fluidity and temporality of digital media have advanced to become an influential, independent factor shaping community opinion” ( David and Baden, 2018 , p. 14). As such, the identity of a closed and inaccessible community and its leadership are challenged by both internal and external actors through the use of digital media.

The study of different digital tools is also considered a relevant subject matter to gain understanding about what tools are more efficient in organizing and mobilizing resources ( Agarwal et al., 2014 ). Technology and digital tools are not value-neutral nor value free, because they influence how people organize, coordinate, and communicate with others ( Hughes, 2004 ; Agarwal et al., 2014 ). For instance, the study on the Russian activists shows how the long-term success of the movement was a result of a centralized, formalized and stable network, wherein its leading representatives and other members were bonded together by a new digital tool ( Toepfl, 2018 ). The use of digital instruments enabled the transformation of an organization that was initially chaotic into a more structured one, as they facilitated the discussion and coordination between the leader and its followers ( Toepfl, 2018 ). This resulted in a more efficient and effective way to achieve consensus.

Taken together, these studies show how technology is far from being a neutral instrument. Rather, digital tools influence power dynamics in any type of organization (e.g., flat, bureaucratic or networked), and at any level. If on one hand, digital tools can lead to the de-structuring of extant hierarchies and challenge organizational boundaries and rules, on the other hand, they can be used as communication and coordination mechanisms that allow leaders to build structured networks from scratch and, through them, reinforce their power.

In sum, these studies stress that, despite the participatory dynamics that characterize social movements, power struggles and hierarchies are still the underlying forces that bond heterogenous groups of people together. Leaders are then the key actors in identifying objectives, orienting followers, and providing a clear identity to organizations, by means of a shared vision ( Gerbaudo, 2017 ; Bakardjieva et al., 2018 ).

The Micro Level of Analysis: Main Categories

The studies that adopt a micro-perspective to the topic of leadership and digital technology can be classified in three different categories, depending on whether they focus on: (1) The increased complexity of C-level roles; (2) The skills e-leaders need; and (3) The practices for leading virtual teams effectively.

The Evolution of C-Level Roles

The huge impact that digitalization has had in the competitive business environment, transforming markets, players, distribution channels, and relationships with customers, has made it necessary for organizations to adopt a high-level strategic view on digital transformation. New responsibilities on the selection of digital technologies that will drive an organization's ability to remain competitive in a highly digitized world, are given mainly to its CEO ( Gerth and Peppard, 2016 ). CEOs in the Digital Age assume the additional role of digital change agents and digital enablers, implying that they should recognize the opportunities offered by new technologies, and also push for their implementation. As suggested by Avolio et al. (2000) , e-leaders have a fundamental role in appropriating the right technology that is suitable to their organizations' needs, but also in transmitting a positive attitude to employees about their adopting of new technology. CEOs are required to instill a digital culture into the top management team, involving it in actively sustain a digital change inside the organization ( Gerth and Peppard, 2016 ). For this matter, a greater interaction is needed between the CEO and the Chief Information Officer (CIO), who will increasingly become a key player in the digital strategy definition and implementation, rather stay confined to an “IT-is-a-mess-now-fix-it” flavor of a role ( Gerth and Peppard, 2016 ; Bekkhus and Hallikainen, 2017 ). Bekkhus and Hallikainen (2017) acknowledge an increased ambidexterity in the role of CIOs and develop a toolbox related to their role as gatekeepers and contributors. In order to reach their goals successfully, CIOs need to have a clear picture of both the characteristics of the digital strategy and the organizational needs it is supposed to satisfy. They should also carefully evaluate the readiness of the organization in every step of the changing process in order to adopt the proper pace. To avoid IT project failures, CEOs need to facilitate the recognition of the CIO's role, as well as promote collaboration between the CIO and other top managers ( Bygstad et al., 2017 ).

As described before, digital technologies are not only used to support internal processes, but are also a way to build relationships with different actors in the external environment. Social media platforms in particular, are de facto powerful tools that C-level executives use to build communications channels with their followers ( Obschonka et al., 2017 ). In a study analyzing the rhetoric of CEOs in social media, Grafström and Falkman (2017) suggest that CEOs' willingness and ability to construct a continuative dialogue through digital channels is a powerful way not only to manage organizational crisis but also to sustain the reputation and the image of the organization, positioning the brand and communicating the organizational values. Thus, as Tsai and Men (2017) unveil, by properly using social media, CEOs, as organizational leaders and spokespersons, can build trust, satisfaction and advocacy among their followers. According to the authors, digital technologies, and social media in particular, support CEOs in becoming “Chief Engagement Officers [who develop] meaningful interpersonal interactions and relationships with today's media savvy publics” ( Tsai and Men, 2017 , p. 1859). Even if CEOs have always been considered the personification of the organization, the rising need for transparency and authenticity has led CEOs to embrace the task of visible, approachable and social leaders who actively contribute to the engagement of followers and costumers ( Tsai and Men, 2017 ).

In sum, C-level managers are faced with higher complexity of roles, related not only to new responsibilities in the digital strategy development, but also in the engagement of stakeholders across the organization's boundaries.

Leaders' Skills in the Digital Era

Defining what skills characterize leaders in the digital era has become a matter of interest in the literature. Studies analyze what are the relevant skills e-leaders should display in order to be effective. In line with the debate on universal and contingency theories, scholars ask to what extent the skills leaders need in order to lead e-businesses differ from the ones needed in traditional organizations ( Horner-Long and Schoenberg, 2002 ). Most studies are based on expert surveys that engage with digital experts, managers, CEOs and Managing Directors of e-businesses ( Lynn Pulley and Sessa, 2001 ; Horner-Long and Schoenberg, 2002 ; Schwarzmüller et al., 2018 ; Sousa and Rocha, 2018 ). A few studies also integrate expert surveys with interviews to IT specialists ( Sousa and Rocha, 2018 ) and C-level managers ( Horner-Long and Schoenberg, 2002 ).

Scholars agree that the introduction of digital tools affects the design of work, and, particularly, how people work together ( Barley, 2015 ; Schwarzmüller et al., 2018 ). For example, digitalization opens up new possibilities such as virtual teams and smart working, introduces new communication tools, increases speed and information access, influences power structures, and increases efficiency and standardization. In order to steer organizations and help them reap the benefits from such digital transformations, leaders may need to develop a variety of different skills. We present below the main skills leaders need in the digital transformation era that have been highlighted in the literature.

Communicating through digital media

Global connectivity and fast exchange of information have created a much more competitive and turbulent environment for e-businesses, which must deal with rapid and discontinuous changes in demand, competition and technology ( Horner-Long and Schoenberg, 2002 ). Scholars agree that the need for speed, flexibility, and easier access to information has facilitated the adoption of flatter and more decentralized organizational structures ( Horner-Long and Schoenberg, 2002 ). In the digital context, knowledge and information become more visible and easier to share, allowing followers to gain more autonomy ( Schwarzmüller et al., 2018 ) and to make their voices heard at all levels of the organization ( Lynn Pulley and Sessa, 2001 ). As information becomes more distributed within the organization, power tends to be decentralized. Digital transformation allows real-time involvement of followers in many decision processes, increasing their participation. Therefore, leaders are expected to adopt a more inclusive style of leading ( Schwarzmüller et al., 2018 ), asking for and taking into account followers' ideas into everyday decision making, using a two-way communication and interaction. Scholars maintain that followers' higher autonomy and participation can lead to a higher sense of responsibility for the work they are accountable for. This in turn should reduce the need for control-seeking behaviors previously exerted by leaders ( Horner-Long and Schoenberg, 2002 ; Schwarzmüller et al., 2018 ).

At the same time, inspiring and motivating employees have become pivotal skills for leaders to master ( Horner-Long and Schoenberg, 2002 ), and seem to be required to an even greater extent in order to encourage the continuous involvement and active participation of followers. Indeed, the same digital tools that provide autonomy to followers, may also drive them toward greater isolation ( Lynn Pulley and Sessa, 2001 ). According to Van Wart et al. (2017) and Roman et al. (2018) , some of the most common problems generated by the digitalization of organizations are worker alienation, weak social bonding, and poor accountability. It is therefore extremely important that leaders support and help followers in dealing with the challenges of greater autonomy and increased job demands, by adopting coaching behaviors that promote their development, provide resources, and assist them in handling tasks ( Schwarzmüller et al., 2018 ).

Similarly, the ability to create a positive organizational environment that fosters a strong sense of collaboration and unity among employees has become vital for leaders to have. Yet, e-leaders' reliance on traditional social skills, such as the abilities of active listening and understanding others' emotions and points of view, may not be enough to warrant success in creating such environments. Rather, they need to integrate these social skills with the ability to master a variety of virtual communication methods ( Roman et al., 2018 ). According to Carte et al. (2006 , p. 326), “while leadership in the more traditional face-to-face context may emerge using a variety of mechanisms, in the virtual context it likely relies largely on the communication effectiveness of the leader.”

Roman et al. (2018 , p. 5) label this skill as e-communication, and define it as “the ability to communicate via ICTs in a manner that is clear and organized, avoids errors and miscommunication, and is not excessive or detrimental to performance.” The leader needs to set the appropriate tone for the communication, while organizing it and providing clear messages. Moreover, the leader needs to master different communication tools, as their communication effectiveness depends largely on the ability to choose the right communication tool. Roman et al. (2018) provide a set of major selection criteria, which includes richness of the tool, synchronicity, speed of feedback, ease of understanding by non-experts, and reprocessing capability (ability to use the communication artifact multiple times in different venues). This ability allows to adapt the communication to the receiver preferences (as it would otherwise happen in a face-to-face interaction), so as to provide a variety of cues that enhance social bonding ( Shachaf and Hara, 2007 ; Stephens and Rains, 2011 ), convey the right message to the target audience, and better manage urgency and complexity.

High speed decision making

One way in which the introduction of technology has changed the organizational life has been the greater need for speed. Scholars agree that e-business leaders are forced to make decisions more rapidly ( Lynn Pulley and Sessa, 2001 ; Horner-Long and Schoenberg, 2002 ). This seems to suggest that decisiveness, and problem-solving abilities keep being extremely relevant for e-leaders, and may become even more prominent in the future ( Horner-Long and Schoenberg, 2002 ). According to Lynn Pulley and Sessa (2001) , never-ending urgency can create situations in which leaders needs to make decisions without having all information or without having time to think and analyze the problem properly, which may lead to falling back onto habitual responses, instead of creating novel and innovative ideas. To help navigate such situations, leaders need to be able to tolerate ambiguity, while being creative at the same time ( Horner-Long and Schoenberg, 2002 ; Schwarzmüller et al., 2018 ). If it is true that the digital world forces leaders to examine problems and provide innovative answers at a faster peace, the use of information technology also allows them to make more informed decisions. Information systems can provide enormous amounts of real-time data. For this reason, the ability to process high volumes of fast-paced incoming and outgoing data (e.g., Big data), in order to analyze it, prioritize and make sense of the relevant information for decision-making, has become and will be even more relevant in the future. Recent research points out that leaders will increasingly need to collaborate with IT managers, providing directions for data analysis and offering meaningful interpretations of results ( Harris and Mehrotra, 2014 ; Vidgen et al., 2017 ).

Managing disruptive change

The fast-paced technological evolution places high demands on organizations' ability to deal with continuously changing conditions and players. Lynn Pulley and Sessa (2001) highlight the constant need for organizations to adapt, foresee opportunities, and sometimes improvise, in order to maintain their competitiveness in the market. Under increasing pressure to innovate, leaders need to undertake an active role in identifying the need for change, as well as handling, and initiating change within their teams and organizations ( Schwarzmüller et al., 2018 ). Horner-Long and Schoenberg (2002) findings confirm that e-leaders tend to show more entrepreneurial and risk-taking characteristics than leaders in traditional contexts. However, continuous change should not disrupt the focus and mission of the organization. While promoting a flexible and innovative attitude in the organization, the leader needs to clarify a common direction. Lynn Pulley and Sessa (2001) identify the ability to inspire and share a common vision about the future of the organization as one of the challenges of e-leaders, who are frequently confronted with the need for change. While acknowledging the importance of this skill, Horner-Long and Schoenberg (2002) did not find it to characterize e-leaders any more than traditional leaders.

Managing connectivity

Scholars maintain that e-leaders also need to foster their networking abilities. Beyond the need to explore and create networks to lobby for resources and stakeholder support ( Horner-Long and Schoenberg, 2002 ) developing social interactions seems to play a key role in favoring innovation. As innovation becomes a top priority, leaders need to understand how to take advantage of networking opportunities ( Avolio et al., 2014 ). The hyper-connected environment, in which leaders operate, especially with the ubiquitous use of social media and other digital platforms, provides new networking opportunities due both to an easier access to larger groups of individuals, and the possibility to establish connections through more immediate communication. New technologies and especially the advent of social networks might have reinforced the perception that being persistently part of the network is compulsory. As reported in Horner-Long and Schoenberg (2002 , p. 616) “in the new economy some leaders do nothing but network - there is no commercial need. It is simply networking for networking's sake.” Although it is a general requirement to be able to create and maintain social relationships with various stakeholders, effective leaders differ specifically in the ability to recognize those relationships that lead to tangible benefits ( Horner-Long and Schoenberg, 2002 ).

The renaissance of technical skills

Lastly, scholars underscore the increased value of technical competencies. This represents a shift from the latest paradigm established over the past four decades, whereby leadership primarily requires emotional and social intelligence competencies that enable the leader to understand, motivate and manage his team effectively. Notwithstanding, leaders also need to understand and manage the use of various technologies. Indeed, IT knowledge and skills have become high on demand requirements to operate in a digitalized environment ( Horner-Long and Schoenberg, 2002 ). Furthermore, the mastery of current technologies must be balanced with the ability to stay current on the newest technological developments ( Roman et al., 2018 ). This emphasizes the need to adopt a life-long learning approach to developing one's digital skills.

Developing leadership skills in the digital era

To lead in the era of digital transformation requires individuals to be both people-oriented and technically minded ( Diamante and London, 2002 ). These two skills often characterize very different profiles of people that, yet, need to come together in order to implement an effective digital transformation in their organization. The case study presented by Coutu (2000) , highlights the need to establish a profitable exchange relationship between leaders of people-oriented (e.g., sales), and IT functions, in order to create a cross-functional and cross-skill contamination. Systematic knowledge dissemination from the individual to the group is highlighted as the most effective way to spread knowledge and expertise across the organization ( Boe and Torgersen, 2018 ). Coutu (2000) addresses how this cross-skill contamination can be performed, by means of implementing reverse-mentoring programs. Nonetheless, the author uncovers the problem of potential generational conflicts, whereby newer generations, who tend to be more knowledgeable and skilled in digital technologies, may gain informational power over others, generating concern and skepticism in older, change averse, individuals ( Coutu, 2000 ).

Studying modern military operational environments, Boe and Torgersen (2018) highlight the need to lead under volatile, uncertain and complex situations, characteristics they find similarly describe the context of modern e-businesses. According to the authors, leadership training needs to combine both technology and change, creating simulations of scenarios in which ambiguous information and improvisation create complex and uncertain conditions.

One way in which exposure to technology and simulations can be combined is through training in virtual spaces ( Lisk et al., 2012 ; Lu et al., 2014 ). In large community games, leaders may have to recruit, motivate, reward, and retain talented team members. They have to make quick decisions that may affect their outcomes in the long-run, for which they need to analyze the environment in order to build and keep their competitive advantage ( Avolio et al., 2014 ). Lu et al. (2014) adopt experiential learning theory ( Kolb and Kolb, 2005 ) to explain e-leadership skills development, referring to activities in which learning is performed in a virtual context. Their study attempts to empirically examine the transferability of virtual experiences into in-role job situations. Results show partial association between virtual games behaviors and hierarchical position of the participants, however, conclusions concerning the transferability of certain skills or experiences gained in virtual games may be highly affected by reverse causality. Ducheneaut and Moore (2005) , conduct a virtual ethnography to show that people participating in multiplayer role-playing games train behaviors related to networking, management and coordination in small groups. However, in a recent review on the use of games, based on digital tools or virtual realities, for training leadership skills, Lopes et al. (2013) highlight a general lack of theoretical grounding in the development and analysis of virtual games. Moreover, they find extant studies rarely show these games affect leadership skill outcomes ( Lopes et al., 2013 ). Robin et al. (2011) find that while simulations facilitate learning, they do not seem to lead to better results than traditional methods. The authors suggest simulations' main advantage lies in the possibility to enable learning in situations where it would otherwise be difficult or impossible. They thus propose the use of a combination of traditional and technology-based training to achieve the most effective learning outcomes.

Leading Virtual Teams

The introduction of digital tools has enable the organizational structure to become not only flatter and decentralized, but also dispersed. One way in which digital technology has shaped organizational life and people management has been by enabling the potential use of virtual teams. Virtual teams are defined as “interdependent groups of individuals that work across time, space, and organizational boundaries with communication links that are heavily dependent upon advanced information technologies” ( Hambley et al., 2007 , p. 1). They have become increasingly pervasive in the last years, especially in multinational organizations ( Gupta and Pathak, 2018 ).

Indeed, several benefits of virtual teams have been acknowledged in the literature. First, the use of virtual teams has allowed for a dramatic reduction of travel times and costs ( Bartol and Liu, 2002 ; Bergiel et al., 2008 ). Second, it has enabled teams to draw upon a varied array of expertise, regardless of location ( Jawadi et al., 2013 ), making it easier to access and recruit talent across the globe. Third, by facilitating the heterogeneity of team members, it has fostered creativity and innovation, due to the possibility of combining different perspectives ( Gupta and Pathak, 2018 ).

Despite its advantages, certain specificities of virtual teams' challenge the traditional way in which teams are managed and led. For instance, virtual teams are characterized by geographical and/or organizational distance. This implies that leaders cannot physically observe team members' behavior nor rely on verbal cues, facial expressions, and other non-verbal communication in order to understand the team's thoughts, feelings, moods and actions. This is considered one of the biggest barriers to developing and managing interpersonal relationships ( Jawadi et al., 2013 ). The heavy dependence on ICT may lead to communication problems, such as failing to distribute information to all team members, understand or convey the level of urgency or importance of the information, and interpret silence ( Cascio and Montealegre, 2016 ). Geographical dispersion often implies cultural diversity between team members, which may affect leaders' ability to build and maintain team spirit and trust ( Gupta and Pathak, 2018 ). According to Sullivan et al. (2015) , space may suppress leadership capacity, even in situations of shared leadership. Moreover, virtual teams are subject to time differences.

In order to overcome these challenges, virtual team leaders need to adopt specific behaviors and practices. One of the most important practices highlighted in the literature involves the setting and periodical revision of communication norms within the team ( Jawadi et al., 2013 ). Instead of focusing on behavioral norms, as in traditional teams, virtual teams require a clear definition of the norms pertaining to their use of communication tools, through witch information flows and activities are performed. Clear communication norms entail a number of advantages for virtual teams, such as: correct exchange of information, regular interaction and feedback, less ambiguity about teamwork processes, better monitoring of each member's contributions, faster detection of problems and mistakes. Moreover, because leaders play a fundamental role in enabling and mediating the communication between team members, they are able to lead them in the construction of a common language. This involves gaining a deep understanding of the underlying meaning of words and expressions used in the team. The mutual understanding of the organizational and social context in which each team member is embedded facilitates this process ( Plowman et al., 2007 ; Bjørn and Ngwenyama, 2009 ; Rafaeli et al., 2009 ).

As mentioned in the previous section, virtual team leaders also need to be able to choose the right communication tools and navigate well through their functionalities and the interactivity across various tools, if they are to avoid disruptions in communication and achieve a more vivid and open communication that favors positive team member relationships ( Jawadi et al., 2013 ). While synchronous communication is considered more appropriate to manage complex, interdependent tasks ( Hambley et al., 2007 ), asynchronous instruments may allow for team members with different backgrounds to adopt their own pace in processing others' ideas or generating new ones ( Malhotra et al., 2007 ). Moreover, asynchronous communication facilitates a continuous flow of information and the ability to work for a greater number of hours ( Gupta and Pathak, 2018 ). Furthermore, leaders need to use multiple channels with different levels of richness ( Hambley et al., 2007 ). According to Hambley et al. (2007) , “a rich medium allows for transmitting multiple verbal and nonverbal clues, using natural language, providing immediate feedback, and conveying personal feelings and emotions.” A richer tool is supposed to lead to better team cohesion. Yet, the authors found mixed results in terms of the association between constructive interaction and task performance ( Hambley et al., 2007 ).

Virtual teams often group together individuals from different educational, functional, geographical and cultural backgrounds. On one hand, such heterogeneity should promote innovative solutions, but on the other hand, it may also undermine collaboration. A virtual team leader thus needs to have good cross-cultural skills ( Schwarzmüller et al., 2018 ), to identify different cultures' characteristics and understand similarities and differences across cultures. Especially at the early stages of a virtual team's lifecycle, the leader needs to assure that the diversity of team members is understood, appreciated, and leveraged. As virtual teams do not usually have the chance to enjoy in-person informal activities typically used to share personal characteristics and abilities and foster team building, the leader needs to share and manage personal information virtually and ensure the team has a clear understanding of each team member's expertise and skills ( Malhotra et al., 2007 ). Once the diversification of skills is acknowledged, virtual teams can also benefit from a clear distribution of roles and tasks ( Jawadi et al., 2013 ). Especially if virtual teams adopt asynchronous communication tools, tasks and schedules need to be clearly defined to avoid delays due to task misallocation or overlapping.

According to Malhotra et al. (2007) , virtual teams may also engage in practices aimed at digitally monitoring the team activity, relying on remote monitoring of virtual communication and participation, as well as document posting. However, Jawadi et al. (2013) notice how monitoring and controlling mechanisms may be negatively perceived by team members. Indeed, their findings show that behaviors directed at monitoring and coordinating team interactions are not associated with higher leader-member relationship quality. According to Carte et al. (2006) , high performing virtual teams are characterized by monitoring behaviors, but only when these are shared between members. Although, traditional performance appraisal and monitoring mechanisms are being replaced by alternative systems that rely on real-time digital feedback, the key features that characterize effective face-to-face feedback have been kept ( Petrucci and Rivera, 2018 ).

Perhaps the best measure of impact of the pervasive adoption of virtual teams in organizations has been the extensive accumulation of literature focused on studying the phenomenon, alongside its antecedents, challenges and outcomes. As our study reveals, scholars have identified a number of best practices, whereby virtual team leaders become the key players in charge of resolving the challenges posed by physical and organizational distance.

However, especially when considering virtual teams, there has been a shift in the literature to steer away from traditional notions of leadership as being assigned to one individual, toward focusing on new conceptualizations of shared and distributed leadership. Virtual teams, which are often cross-functional, are indeed characterized by a relative absence of formal hierarchical authority ( Pearce et al., 2009 ). In the same way that the need for speed in responding to accelerated environmental change and higher connectivity led to the development of virtual teams, that same need may be driving the flattening of hierarchical structures toward more evenly distributed, shared and empowered leadership among virtual team members ( Pearce et al., 2009 ). As such, virtual teams are often left alone to shape and define their own leadership style, which may encourage all team members to perceive themselves as leaders and drive the collective development of leadership skills ( Gupta and Pathak, 2018 ). In these so called self-managing work teams (SMWTs; Manz and Sims, 1987 ; Druskat and Wheeler, 2003 ), decisions and leadership responsibilities are equitably allocated among team members, who are also engaged in supporting and accompanying each other in the accomplishment of their tasks. The concept of shared leadership does not necessarily imply the rejection of a “formal” leader, but introduces the idea that any team member may be a leader, and as such, is expected to assess the team in its context and assert what is best for the team: whether to volunteer himself as team leader or empower any fellow team member(s) to serve the team as leader(s). This process leads to the creation of a shared understanding of both the leadership responsibilities and the power dynamics within the team ( Grisoni and Beeby, 2007 ; Hoch and Kozlowski, 2014 ; Hoegl and Muethel, 2016 ).

Toward The Future: Research Directions

Despite the urgency felt by scholars to understand how leaders keep the pace with technological change, the literature seems to lack a shared approach in studying and theorizing about this phenomenon. Although researchers have been introducing relevant new concepts, such as e-leader and e-organizations, there is a shortage of well-established and consensual definitions in the literature. Our review reveals scholars have relied on several leadership theories to explain the relationship between leadership and digital transformation. However, we question whether theories based on traditional views of industrial organization and business, that still prevail in the literature, are the most suitable to comprehend the multifaceted phenomenon of digital transformation and its impact on all matters leadership of organizations, communities, teams, and even self. As suggested by Kahai et al. (2013) , scholars may need to go beyond traditional leadership theories to explain the impact digitalization exerts on leadership and leaders. Are the existing theories in social sciences able to explain the antecedents, characteristics and outcomes of this disruptive phenomenon or do we need new theoretical lenses to make sense of how leaders may respond to this change?

One of the most complex and pressing issues concerns e-leaders (un)ethical behaviors. Notably, the higher risk leaders now face of engaging in unethical uses of personal and sensitive information, or the inexistence of a code of conduct for ethical leadership behavior are critical concerns to raise in any debate of e-leadership ( Lee, 2009 ). Collaboration through digital technologies brings about new questions regarding the role leaders may play in the digital environment. What is the role of leaders in guiding an ethical appropriation of digital technologies? What can e-leaders do in order to be an example and instill an ethical culture within their followers? How do digital tools such as social media and online communities and forums change the conditions under which interactions occur and how do these affect the maintenance of ethical behaviors? These are questions that future research is pressed to answer. While the theoretical debate has already started to address some of these questions, empirical research remains considerably underdeveloped.

The present review uncovers a shortage of contributions addressing the role that institutions play in supporting ethical behaviors of leaders. In particular, what remains unclear is whether and how leaders will be prepared to face the new wave of data and policies that affect their ability to manage privacy and regulatory issues. Studies in this area are thus highly encouraged.

The leader-follower relationships mediated by ICTs can also be affected by concerns for privacy and information that the parties do not want to share. Social media interactions, for example, leave digital footprints that can be monitored by leaders and organizations, which may compromise the interactions and responses of followers that feel their privacy is at risk. The same can be said regarding the instruments that digital technologies provide for tracing personal productivity. Project management applications, for instance, trace individual contributions to a certain project, but can challenge an impartial evaluation if the relationship between individual effort and contribution to the results is not clear, thus putting into question the trust in the relationship with leaders. Future research should consider these aspects and work toward a broader comprehension of how to balance the need for higher transparency in ICT- mediated relationships with followers' higher autonomy and need for privacy.

We acknowledge that the introduction and use of digital tools it strictly linked to organizational cultures that value the use of technology and establishes the readiness of organizations to successfully implement digital tools. Therefore, we suggest further research needs to investigate the extent to which culture affects the selection and effective implementation of digital technologies within organizations. Answering to this question also provides relevant information on how digital technology alters organizational identity and shapes new organizational boundaries. Exploring this line of inquiry using both theoretical and empirical approaches, may inform the creation of new organizational identities, and their relationship with different types of organizations and institutions.

Since digitalization is enabling a growing propensity to share information, organizational boundaries are becoming more fluid and expanding outside the formal organization. Hence, collective forms of leadership are expected to increase. Notably, distributed or shared leadership is supposed to gain momentum, especially if it is considered a better fit to the characteristics of virtual teams, such as the informal nature of its communication channels, task interdependence and team member autonomy ( Avolio et al., 2014 ; Hoch and Kozlowski, 2014 ). What remains unclear is the role that leaders play in recognizing and encouraging distributed leadership in teams. Moreover, how much does the success of shared leadership styles depend on the organizational culture? What is the effect of shared leadership on virtual team dynamics? We claim that these are questions that should be explored with greater detail in the future.

Networked organizations, as well as the rise of virtual teams, speak volumes about the endless connectivity possibilities that digital technology has enabled. However, empirical studies on virtual teams also highlight that digital tools and media can disconnect individuals and undermine established power dynamics. Despite the relevance of increased connectivity, only a few studies adopt a network approach to understand how leaders and followers are interconnected to one another.

Literature has already acknowledged that the lack of face-to-face interactions makes the task of leading virtual teams a more complex job ( Purvanova and Bono, 2009 ). Indeed, the physical and cultural distance that characterizes virtual teams threatens the ability to build trust, create commitment and enhance cohesion among team members ( Hoch and Kozlowski, 2014 . As suggested by Lee (2009) trust in virtual teams is related to ethics: the way in which leaders and team members behave, the extent to which they demonstrate transparency when interacting with others, the integrity and compliance to the rules and procedures of the organization and the team are key issues that should not be neglected. However, little is known about the methods and behaviors that effective leaders can adopt in order to build trust in virtual teams. Literature on this topic needs contributions that focus specifically on the process of trust creation in virtual teams, describing its characteristics and mechanisms and informing about which digital tools can be used to support such process. Indeed, along with the ability of creating trust among team members, virtual team leaders are required to have the ability of choosing and exploiting the right communication tools ( Jawadi et al., 2013 ; Roman et al., 2018 ). Future research should try to uncover the effect different characteristics of communication tools may have on team dynamics and leader-followers relationships.

The lack of face-to-face interaction also creates new challenges in the deployment of social skills. Processes related to interpersonal understanding may be inhibited by distance and by the use of interfaces. Indeed, comparing traditional face-to-face teams and pure virtual teams, Balthazard et al. (2009) found that leader characteristics that are easier to perceive from nonverbal cues, such as personality traits, predicted the emergence of transformational leadership in face-to-face teams, but not in computer-mediated teams. Considering the importance of social understanding and affect-based perceptions, we encourage future research that analyzes the ways in which leaders can create positive emotional contagion, through technology. For example, it could be interesting to inquire whether the use of facial/emotional recognition devices ( Pentland and Choudhury, 2000 ), and affective haptics ( Arafsha et al., 2012 ) can contribute to interpersonal emotional understanding and sharing, and how it affects leader-follower relationships and team dynamics. Balthazard et al. (2009) found written communication quality to be positively related to the emergence of transformational leadership in virtual teams. Indeed, the increasing adoption of written communication-based tools such as chats, social media, or document sharing platforms, calls for the use of linguistic analysis of online communication to understand how leaders effectively instill emotions, convey their vision, or communicate urgency through text.

As suggested by Avolio et al. (2014) , leadership in the digital world may be influenced by gender. Men and women may adopt different criteria in choosing which technologies to adopt. However, this topic of research has earned little attention in the literature. We claim that other studies are needed to investigate more in depth gender differences, and its effect on organizational outcomes.

Another topic that future researcher needs to address regards the way in which leaders can develop the skills needed to perform in the digital era. Some scholars maintain virtual games might be useful instruments to foster both social and technical skills ( Ducheneaut and Moore, 2005 ; Lu et al., 2014 ). However, findings have not yet showed whether virtual games have a clear effect on social and digital skills development. We suggest future research could inspect what types of virtual behaviors foster team engagement and higher team performance in multiplayer virtual games, while examining the role of these variables in organizational settings. Other scholars propose digital natives and technical experts in organizations may be engaged in the training of those who are less familiar with or demonstrate a negative attitude toward the adoption of technology, for example by means of reverse mentoring programs ( Coutu, 2000 ). However, conditions that can favor a successful digital transformation of organizations should be analyzed. The technological skill advantage of young generations may destabilize traditional power relations. A closer look to this phenomenon is suggested.

In a digital world where physical presence is becoming unnecessary, the possibility that some leadership responsibilities begin to be performed by AI-based technology is not unrealistic. A tough debate is raising awareness as to whether robots can be programmed to express emotions and how this fosters the possibility that robots may be better leaders than humans ( Avolio et al., 2014 ). Complementing the literature that has so far stressed the importance of emotions and emotional intelligence for leaders' performance (see for instance Boyatzis, 2006 ; Boyatzis et al., 2017 ), future research should shed light on whether and how robots, algorithms and technological tools substitute or complement leaders.

Even if macro and micro level of analysis are explored by social science scholars, management literature would still lack the analysis of the phenomenon of leadership and digitalization at the meso-level. A promising way of combining micro and macro levels of theorizing might be to introduce a multiple level of analysis. Some of the papers in our dataset move toward this direction, however, it is not clear how digitalization is affecting relationships between diverse organizations.

Finally, from a methodological point of view, our study shows a plethora of methods employed by scholars to analyze leaders' behavior ( Hambley et al., 2007 ; Malhotra et al., 2007 ; Jawadi et al., 2013 ), leaders' skills ( Horner-Long and Schoenberg, 2002 ; Roman et al., 2018 ), or technology adoption ( Bartol and Liu, 2002 ; Weiner et al., 2015 ). If on one hand, this richness provides a portfolio of techniques that scholars could use depending on the subject of analysis, on the other hand, it confirms that there is still a confusion about how to monitor this recent phenomenon. Moreover, we observe that contributions are confined within their own disciplinary frontiers. For instance, social movements literature, that mainly draws on qualitative methods such as ethnography, case study, and interviews, should inform organizational scholars how to observe power relations within companies. Extant contributions investigating what are the skills leaders facing the digital transformation require are based mainly on experts' surveys and interviews. Literature reveals a lack of empirical research which examines the relationship between identified leadership skills and successful performance in highly digitalized organizations. Future studies should also take into account how much this relationship may be affected by the context in which the leader operates.

Nowadays, digital transformation is an unavoidable choice for any company, regardless of size or sector. Leaders cope with new tools on a daily basis and they make decisions according to the data they have access to. Therefore, we highly encourage future research to shed more light on the effect of digital transformation on leadership, both at organizational and individual level. If the debate about the relationship between human beings and machine is not a recent one ( Turing, 1950 ), not to management literature, nor social sciences in general, the relationship between digital transformation and leadership requires updated lenses. This systematic review offers a structured framework of a promising field, and we hope it will help future research generate coherent efforts to garner novel and relevant knowledge in this research topic.

The purpose of this review was 3-fold. First, we discussed how leadership in the digital era has been conceptualized, reviewing the theoretical perspectives that have been used in prior research. Our review did not reveal a strong unifying theory of the relationship between leadership and digital transformation, thus calling for more attention to theoretical contributions.

Second, we mapped the academic debate on the relationship between digital transformation and leadership, organizing and structuring the main emerging themes at macro and micro level of analysis. We observed that both contributions with micro and macro approaches underscore that information technology and strategic management need greater alignment. Digital transformation is successful in the long term when the overall organizational objectives match the need to adopt a new digital tools or instruments. In a similar vein, individuals embrace technological advancement only when they perceive it is relevant to their tasks. It is an important responsibility of the leader, particularly of C-level leaders, to steer this strategic alignment and the proliferation of a digital culture.

In a networked economy, the digital transformation has led organizations to open their boundaries, and connect with other industries, stakeholders, and customers, to generate innovation. From a micro perspective, this openness is also required by leaders who need to invest in networking. This means to be “out there” ( Grafström and Falkman, 2017 ), present in the network ( Gordon, 2007 ), and willing to communicate with different types of stakeholders, through digital tools and social media. Especially for leaders, the digital tools are no longer a distant container of everyday life; rather, they are instruments in which everyday life emerges ( Gordon, 2007 ).

Although the introduction of digital tools influenced organizational boundaries and leadership boundaries, for instance favoring the development of concepts such as shared leadership, studies show that trust among members and employees is still achieved and maintained through leaders' intervention ( Carte et al., 2006 ). Cascio and Montealegre (2016 , p. 356), reminds us that inspirational leaders will remain pivotal in making the right decisions, as “humans will continue to enjoy a strong comparative advantage over machines.” However, the growing development and use of AI-based technology to make decisions, calls for a closer understanding of what leadership will mean in the future. Growing ethical concerns related to the application of AI in managerial activities as well as to the appropriation of technology and data are becoming an urgent topic to address.

To overcome the challenges derived from the digital transformation, leaders are required to develop a combination of digital and human skills, mainly related to the ability to communicate effectively in a digitalized context, create cohesion between geographically distant followers, foster initiative and change attitudes, and deal with complex and fast problem solving.

Third, we highlighted the current gaps and open questions in the literature, and laid out a future research agenda that targets opportunities for the empirical and theoretical advancement of knowledge.

While our review is timely and includes the most recent contributions, some limitations should be considered and overcome in future studies. First, since our concern was to map prior research, we have not provided detailed propositions to the suggested categories, a void that should be addressed by future studies. The second concern regards the sample. We drew from the Scopus database only. Albeit we checked other databases to avoid potential bias, we may have missed some relevant articles contained elsewhere. Third, despite the rigorous procedure of our systematic review, a limitation is ascribed to the inclusion of only peer-reviewed articles and conference proceedings. A future review should also include industry research reports, professional outlets publishing research-based findings, and other non-pear reviewed manuscripts to better clarify how the multidimensional phenomenon of digitalization is affecting organizations and leadership. Finally, we excluded, as per our boundary conditions, articles that considered organizations as leaders in the digital transformation, and studies that discussed about digital platforms. Future studies should adopt a broader overview of the macro-organizational and strategic effects in order to understand how digital transformation is implemented across different organizations, communities and teams.

Author Contributions

LC and EB contributed conception and design of the study. LC, EB, and RZ organized and analyzed the database. LC and EB wrote the first draft of the manuscript. RZ wrote sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: leadership, e-leadership, digital transformation, digital technology, literature review, skills, ethics, virtual teams

Citation: Cortellazzo L, Bruni E and Zampieri R (2019) The Role of Leadership in a Digitalized World: A Review. Front. Psychol. 10:1938. doi: 10.3389/fpsyg.2019.01938

Received: 25 February 2019; Accepted: 07 August 2019; Published: 27 August 2019.

Reviewed by:

Copyright © 2019 Cortellazzo, Bruni and Zampieri. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Laura Cortellazzo, laura.cortellazzo@unive.it

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Priorities and challenges for health leadership and workforce management globally: a rapid review

Carah alyssa figueroa.

School of Public Health and Community Medicine, University of New South Wales, UNSW, Sydney, 2052 Australia

Reema Harrison

Ashfaq chauhan, associated data.

The data that support the findings of this review are included in this published article.

Health systems are complex and continually changing across a variety of contexts and health service levels. The capacities needed by health managers and leaders to respond to current and emerging issues are not yet well understood. Studies to date have been country-specific and have not integrated different international and multi-level insights. This review examines the current and emerging challenges for health leadership and workforce management in diverse contexts and health systems at three structural levels, from the overarching macro (international, national) context to the meso context of organisations through to the micro context of individual healthcare managers.

A rapid review of evidence was undertaken using a systematic search of a selected segment of the diverse literature related to health leadership and management. A range of text words, synonyms and subject headings were developed for the major concepts of global health, health service management and health leadership. An explorative review of three electronic databases (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content between January 2010 to July 2018. A search strategy was then applied to the key journals identified, in addition to hand searching the journals and reference list of relevant papers identified. Inclusion criteria were independently applied to potentially relevant articles by three reviewers. Data were subject to a narrative synthesis to highlight key concepts identified.

Sixty-three articles were included. A set of consistent challenges and emerging trends within healthcare sectors internationally for health leadership and management were represented at the three structural levels. At the macro level these included societal, demographic, historical and cultural factors; at the meso level, human resource management challenges, changing structures and performance measures and intensified management; and at the micro level shifting roles and expectations in the workplace for health care managers.

Contemporary challenges and emerging needs of the global health management workforce orient around efficiency-saving, change and human resource management. The role of health managers is evolving and expanding to meet these new priorities. Ensuring contemporary health leaders and managers have the capabilities to respond to the current landscape is critical.

Health systems are increasingly complex; encompassing the provision of public and private health services, primary healthcare, acute, chronic and aged care, in a variety of contexts. Health systems are continually evolving to adapt to epidemiological, demographic and societal shifts. Emerging technologies and political, economic, social, and environmental realities create a complex agenda for global health [ 1 ]. In response, there has been increased recognition of the role of non-state actors to manage population needs and drive innovation. The concept of ‘collaborative governance,’ in which non-health actors and health actors work together, has come to underpin health systems and service delivery internationally [ 1 ] in order to meet changing expectations and new priorities. Seeking the achievement of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), particularly in low- and middle-income countries, have been pivotal driving forces [ 2 ]. Agendas for change have been encapsulated in reforms intended to improve the efficiency, equity of access, and the quality of public services more broadly [ 1 , 3 ].

The profound shortage of human resources for health to address current and emerging population health needs across the globe was identified in the World Health Organization (WHO) landmark publication ‘Working together for health’ and continues to impede progress towards the SDGs [ 4 ]. Despite some improvements overall in health workforce aggregates globally, the human resources for health challenges confronting health systems are highly complex and varied. These include not only numerical workforce shortages but imbalances in skill mix, geographical maldistribution, difficulty in inter-professional collaboration, inefficient use of resources, and burnout [ 2 , 5 , 6 ]. Effective health leadership and workforce management is therefore critical to addressing the needs of human resources within health systems and strengthening capacities at regional and global levels [ 4 , 6 – 8 ].

While there is no standard definition, health leadership is centred on the ability to identify priorities, provide strategic direction to multiple actors within the health system, and create commitment across the health sector to address those priorities for improved health services [ 7 , 8 ]. Effective management is required to facilitate change and achieve results through ensuring the efficient mobilisation and utilisation of the health workforce and other resources [ 8 ]. As contemporary health systems operate through networks within which are ranging levels of responsibilities, they require cooperation and coordination through effective health leadership and workforce management to provide high quality care that is effective, efficient, accessible, patient-centred, equitable, and safe [ 9 ]. In this regard, health leadership and workforce management are interlinked and play critical roles in health services management [ 7 , 8 ].

Along with health systems, the role of leaders and managers in health is evolving. Strategic management that is responsive to political, technological, societal and economic change is essential for health system strengthening [ 10 ]. Despite the pivotal role of health service management in the health sector, the priorities for health service management in the global health context are not well understood. This rapid review was conducted to identify the current challenges and priorities for health leadership and workforce management globally.

This review utilised a rapid evidence assessment (REA) methodology structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [ 11 ]. An REA uses the same methods and principles as a systematic review but makes concessions to the breadth or depth of the process to address key issues about the topic under investigation [ 12 – 14 ]. An REA provides a balanced assessment of what is already known about an issue, and the strength of evidence. The narrower research focus, relative to full systematic reviews, make REAs helpful for systematically exploring the evidence around a particular issue when there is a broad evidence base to explore [ 14 ]. In the present review, the search was limited to contemporary literature (post 2010) selected from leading health service management and global health journals identified from exploring major electronic databases.

Search strategy

An explorative review of three core databases in the area of public health and health services (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content. These databases were selected as those that would be most relevant to the focus of the review and have the broadest range of relevant content. A range of text words, synonyms and subject headings were developed for the major constructs: global health, health service management and health leadership, priorities and challenges. Regarding health service management and health leadership, the following search terms were used: “healthcare manag*” OR “health manag*” OR “health services manag*” OR “health leader*”. Due to the large volume of diverse literature generated, a systematic search was then undertaken on the key journals that produced the largest number of relevant articles. The journals were selected as those identified as likely to contain highly relevant material based on an initial scoping of the literature.

Based on the initial database search, a systematic search for articles published in English between 1 January 2010 and 31 July 2018 was undertaken of the current issues and archives of the following journals: Asia-Pacific Journal of Health Management; BMC Health Services Research; Healthcare Management Review; International Journal of Healthcare Management; International Journal of Health Planning and Management; Journal of Healthcare Management; Journal of Health Organisation and Management; and, Journal of Health Management. Hand-searching of reference lists of identified papers were also used to ensure that major relevant material was captured.

Study selection and data extraction

Results were merged using reference-management software (Endnote) and any duplicates removed. The first author (CF) screened the titles and abstracts of articles meeting the eligibility criteria (Table ​ (Table1). 1 ). Full-text publications were requested for those identified as potentially relevant. The inclusion and exclusion criteria were then independently applied by two authors. Disagreements were resolved by consensus or consultation with a third person, and the following data were extracted from each publication: author(s), publication year, location, primary focus and main findings in relation to the research objective. Sixty-three articles were included in the final review. The selection process followed the PRISMA checklist [ 11 ] as shown in Fig. ​ Fig.1 1 .

Eligibility criteria for selecting studies for the review

PRISMA flow chart of the literature search, identification, and inclusion for the review

Data extraction and analysis

A narrative synthesis was used to explore the literature against the review objective. A narrative synthesis refers to “an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis” [ 15 ]. Firstly, an initial description of the key findings of included studies was drafted. Findings were then organised, mapped and synthesised to explore patterns in the data.

Search results

A total of 63 articles were included; Table ​ Table2 2 summarizes the data extraction results by region and country. Nineteen were undertaken in Europe, 16 in North America, and one in Australia, with relatively fewer studies from Asia, the Middle East, and small island developing countries. Eighteen qualitative studies that used interviews and/or focus group studies [ 16 – 32 ] were identified. Other studies were quantitative [ 33 – 39 ] including the use of questionnaires or survey data, or used a mixed-method approach [ 40 – 44 ]. Other articles combined different types of primary and secondary data (key informant interviews, observations, focus groups, questionnaire/survey data, and government reports). The included literature also comprised 28 review articles of various types that used mixed data and bibliographic evidence.

Literature included in this review, by context and their references

a refers to more than one country situated in different regions including Europe, North America, Asia, and Africa

Key challenges and emerging trends

A set of challenges and emerging trends were identified across healthcare sectors internationally. These were grouped at three levels: 1) macro, system context (society, demography, technology, political economy, legal framework, history, culture), 2) meso, organisational context (infrastructure, resources, governance, clinical processes, management processes, suppliers, patients), and 3) micro context related to the individual healthcare manager (Table ​ (Table3). 3 ). This multi-levelled approach has been used in previous research to demonstrate the interplay between different factors across different levels, and their direct and indirect reciprocal influences on healthcare management policies and practices [ 45 ].

Overview and types of challenges and emerging trends for healthcare managers internationally within the included literature

Societal and system-wide (macro)

Population growth, ageing populations, and increased disease burdens are some of the common trends health systems are facing globally. Developing and developed countries are going through demographic and epidemiological transitions; people are living longer with increasing prevalence of chronic diseases requiring health managers and leaders to adjust to shifting healthcare needs at the population level, delivering preventative and long-term care beyond acute care. Countries in Africa, Europe, the Pacific Islands, Middle East, Asia and Caribbean are seeing an increase in number of patients with non-communicable diseases and communicable diseases [ 21 , 46 – 52 ].

Although many countries have similar emerging health system concerns, there are some differences in the complexities each country faces. For many small countries, outmigration, capacity building and funding from international aid agencies are affecting how their health systems operate, while in many larger countries, funding cuts, rise in private health insurance, innovations, and health system restructuring are major influences [ 21 , 34 , 50 , 53 , 54 ]. In addition, patients are increasingly health literate and, as consumers, expect high-quality healthcare [ 34 , 53 , 54 ]. However, hospitals and healthcare systems are lacking capacity to meet the increased demand [ 16 , 34 , 43 ].

Scientific advances have meant more patients are receiving care across the health system. It is imperative to have processes for communication and collaboration between different health professionals for high-quality care. However, health systems are fragmented; increasing specialisation is leading to further fragmentation and disassociation [ 31 , 54 , 55 ]. Adoption of technological innovations also require change management, hospital restructure, and capacity building [ 56 – 58 ].

Changes in health policies and regulations compound the challenge faced by healthcare managers and leaders to deliver high quality care [ 53 , 54 , 59 ]. Political reforms often lead to health system restructuring requiring change in the values, structures, processes and systems that can constrain how health managers and leaders align their organisations to new agendas [ 24 , 28 , 31 , 60 ]. For example, the distribution of health services management to local authorities through decentralisation has a variable impact on the efficacy and efficiency of healthcare delivery [ 24 , 27 , 35 , 59 ].

Governments’ decisions are often made focusing on cost savings, resulting in budgetary constraints within which health systems must operate [ 16 , 19 , 53 , 61 ]. Although some health systems have delivered positive results under such constraint [ 53 ], often financial resource constraints can lead to poor human and technical resource allocation, creating a disconnect between demand and supply [ 23 , 27 , 40 , 47 , 57 ]. To reduce spending in acute care, there is also a push to deliver health services in the community and focus on social determinants of health, though this brings further complexities related to managing multiple stakeholder collaborations [ 27 , 32 , 34 , 38 , 40 , 49 , 55 ].

Due to an increase in demand and cost constraints, new business models are emerging, and some health systems are resorting to privatisation and corporatisation [ 22 , 48 , 62 ]. This has created competition in the market, increased uptake of private health insurance and increased movement of consumers between various organisations [ 22 , 48 ]. Health managers and leaders need to keep abreast with continuously changing business models of care delivery and assess their impact [ 59 , 62 ]. The evolving international health workforce, insufficient numbers of trained health personnel, and maintaining and improving appropriate skill mixes comprise other important challenges for managers in meeting population health needs and demands (Table ​ (Table3 3 ).

Organisational level (meso)

At the organisation level, human resource management issues were a central concern. This can be understood in part within the wider global human resources for health crisis which has placed healthcare organisations under intense pressure to perform. The evidence suggests healthcare organisations are evolving to strengthen coordination between primary and secondary care; there is greater attention to population-based perspectives in disease prevention, interdisciplinary collaboration, and clinical governance. These trends are challenged by the persistence of bureaucratic and hierarchical cultures, emphasis on targets over care quality, and the intensification of front-line and middle-management work that is limiting capacity.

Healthcare managers and leaders also face operational inefficiencies in providing primary health and referral services to address highly complex and shifting needs which often result in the waste of resources [ 49 , 63 , 64 ]. Considering the pace of change, organisations are required to be flexible and deliver higher quality care at lower cost [ 21 , 53 , 65 ]. To achieve this, many organisations in developing and developed countries alike are adopting a lean model [ 17 , 21 ]. However, there are challenges associated with ensuring sustainability of the lean system, adjusting organisational hierarchies, and improving knowledge of the lean model, especially in developing countries [ 17 , 21 ].

Healthcare organisations require various actors with different capabilities to deliver high quality care. However, a dominant hierarchical culture and lack of collaborative and distributed culture can limit the performance of healthcare organisations [ 22 , 36 , 54 ]. In addition, considering high turnover of executive leadership, healthcare organisations often rely on external talent for succession management which can reduce hospital efficiency [ 44 , 66 ]. Other contributors to weakened hospital performance include: the lack of allocative efficiency and transparency [ 24 , 30 , 64 , 67 ]; poor hospital processes that hamper the development of effective systems for the prevention and control of hospital acquired infections (HAIs) [ 53 , 68 ]; and, payment reforms such as value-based funding and fee-for-service that encourage volume [ 18 , 23 , 24 , 61 , 62 , 69 , 70 ].

Managerial work distribution within organisations is often not clearly defined, leading to extra or extreme work conditions for middle and front-line managers [ 29 , 42 , 53 , 70 ]. Unregulated and undefined expectations at the organisation level leads to negative effects such as stress, reduced productivity, and unpredictable work hours, and long-term effects on organisational efficiency and delivery of high quality care [ 22 , 28 , 29 , 37 , 42 , 51 , 71 ]. Furthermore, often times front-line clinicians are also required to take the leadership role in the absence of managers without proper training [ 20 ]. Despite this, included studies indicate that the involvement of middle and front-line managers in strategic decision-making can be limited due to various reasons including lack of support from the organisation itself and misalignment of individual and organisational goals [ 16 , 26 , 31 , 72 ].

Individual level (micro)

Worldwide, middle and front-line health managers and leaders are disproportionately affected by challenges at the system and organisational level, which has contributed to increasing and often conflicting responsibilities. Some countries are experiencing a growth in senior health managers with a clinical background, while in other countries, the converse is apparent. Indistinct organisational boundaries, increasing scope of practice, and lack of systemic support at policy level are leaving healthcare managers with undefined roles [ 28 , 59 ]. Poorly defined roles contribute to reduced accountability, transparency, autonomy, and understanding of responsibilities [ 24 , 30 , 31 , 67 ]. Studies also indicate a lack of recognition of clinical leaders in health organisations and inadequate training opportunities for them as such [ 20 , 67 ].

The number of hybrid managers (performing clinical and managerial work concurrently) in developed countries is increasing, with the perception that such managers improve the clinical governance of an organization. In contrast, the number of non-clinical managers in many developing countries appears to be increasing [ 63 , 73 – 75 ]. Included studies suggest this approach does not necessarily improve manager-clinical professional relationships or the willingness of clinicians becoming managers, limiting their participation in strategic decisions [ 28 , 70 , 71 , 74 ].

This rapid review highlights the current global climate in health service management, the key priority areas, and current health management approaches being utilised to address these. The multitude of issues emerging demonstrate the complex and evolving role of health service management in the wider complex functioning of health systems globally in a changing healthcare landscape. Key themes of achieving high quality care and sustainable service delivery were apparent, often evidenced through health reforms [ 5 ]. The influence of technological innovation in both its opportunities and complexities is evident worldwide. In the context of changing healthcare goals and delivery approaches, health management is seeking to professionalise as a strategy to build strength and capacity. In doing so, health managers are questioning role scope and the skills and knowledge they need to meet the requirements of the role.

Global challenges facing health management

Understanding how the features of the macro, meso and micro systems can create challenges for managers is critical [ 19 ]. With continual healthcare reform and increasing health expenditure as a proportion of GDP, distinct challenges are facing high-income Organisation for Economic Co-operation and Development (OECD) countries, middle-income rapidly-developing economies, and low-income, resource-limited countries. Reforms, especially in OECD countries, have been aimed at controlling costs, consolidating hospitals for greater efficiencies, and reconfiguring primary healthcare [ 1 , 76 ]. The changing business models for the delivery of care have wider implications for the way in which health managers conceptualise healthcare delivery and the key stakeholders [ 59 ], for example, the emerging role of private healthcare providers and non-health actors in public health. Changes to the business model of healthcare delivery also has implications for the distribution of power amongst key actors within the system. This is evident in the evolved role of general practitioners (GPs) in the UK National Health Service as leaders of Clinical Commissioning Groups (CCGs). Commissioning requires a different skill set to clinical work, in terms of assessing financial data, the nature of statutory responsibilities, and the need to engage with a wider stakeholder group across a region to plan services [ 77 ]. With new responsibilities, GPs have been required to quickly equip themselves with new management capabilities, reflecting the range of studies included in this review around clinician managers and the associated challenges [ 18 , 28 , 53 , 63 , 70 , 71 , 74 , 75 ].

Central to the role of healthcare managers is the ability to transition between existing and new cultures and practices within healthcare delivery [ 59 ]. Bridging this space is particularly important in the context of increasingly personalized and technologically-driven healthcare delivery [ 54 ]. While advances in knowledge and medical technologies have increased capability to tackle complex health needs, the integration of innovations into existing healthcare management practices requires strong change management [ 73 ]. Health leaders and managers need to be able to rapidly and continually assess the changes required or upon them, the implications, and to transform their analysis into a workable plan to realise change [ 10 ]. Focusing only on the clinical training of health professionals rather than incorporating managerial and leadership roles, and specifically, change management capability may limit the speed and success of innovation uptake [ 22 ].

Implications

Our findings highlight the implications of current priorities within the health sector for health management practice internationally; key issues are efficiency savings, change management and human resource management. In the context of efficiency approaches, health system and service managers are facing instances of poor human and technical resource allocation, creating a disconnect between demand and supply. At the service delivery level, this has intensified and varied the role of middle managers mediating at two main levels. The first level of middle-management is positioned between the front-line and C-suite management of an organisation. The second level of middle-management being the C-suite managers who translate regional and/or national funding decisions and policies into their organisations. Faced with increasing pace of change, and economic and resource constraints, middle managers across both levels are now more than ever exposed to high levels of stress, low morale, and unsustainable working patterns [ 29 ]. Emphasis on cost-saving has brought with it increased attention to the health services that can be delivered in the community and the social determinants of health. Connecting disparate services in order to meet efficiency goals is a now a core feature of the work of many health managers mediating this process.

Our findings also have implications for the conceptualisation of healthcare management as a profession. The scale and increasing breadth of the role of health leaders and managers is evident in the review. Clarifying the professional identity of ‘health manager’ may therefore be a critical part of building and maintaining a robust health management workforce that can fulfil these diverse roles [ 59 ]. Increasing migration of the healthcare workforce and of population, products and services between countries also brings new challenges for healthcare. In response, the notion of transnational competence among healthcare professionals has been identified [ 78 ]. Transnational competence progresses cultural competence by considering the interpersonal skills required for engaging with those from diverse cultural and social backgrounds. Thus, transnational competence may be important for health managers working across national borders. A key aspect of professionalisation is the education and training of health managers. Our findings provide a unique and useful theoretical contribution that is globally-focused and multi-level to stimulate new thinking in health management educators, and for current health leaders and managers. These findings have considerable practical utility for managers and practitioners designing graduate health management programs.

Limitations

Most of the studies in the field have focused on the Anglo-American context and health systems. Notwithstanding the importance of lessons drawn from these health systems, further research is needed in other regions, and in low- and middle-income countries in particular [ 79 ]. We acknowledge the nuanced interplay between evidence, culture, organisational factors, stakeholder interests, and population health outcomes. Terminologies and definitions to express global health, management and leadership vary across countries and cultures, creating potential for bias in the interpretation of findings. We also recognise that there is fluidity in the categorisations, and challenges arising may span multiple domains. This review considers challenges facing all types of healthcare managers and thus lacks discrete analysis of senior, middle and front-line managers. That said, managers at different levels can learn from one another. Senior managers and executives may gain an appreciation for the operational challenges that middle and front-line managers may face. Middle and front-line managers may have a heightened awareness of the more strategic decision-making of senior health managers. Whilst the findings indicate consistent challenges and needs for health managers across a range of international contexts, the study does not capture country-specific issues which may have consequences at the local level. Whilst a systematic approach was taken to the literature in undertaking this review, relevant material may have been omitted due to the limits placed on the rapid review of the vast and diverse health management literature. The inclusion of only materials in English language may have led to further omissions of relevant work.

Health managers within both international and national settings face complex challenges given the shortage of human resources for health worldwide and the rapid evolution of national and transnational healthcare systems. This review addresses the lack of studies taking a global perspective of the challenges and emerging needs at macro (international, national and societal), meso (organisational), and micro (individual health manager) levels. Contemporary challenges of the global health management workforce orient around demographic and epidemiological change, efficiency-saving, human resource management, changing structures, intensified management, and shifting roles and expectations. In recognising these challenges, researchers, management educators, and policy makers can establish global health service management priorities and enhance health leadership and capacities to meet these. Health managers and leaders with adaptable and relevant capabilities are critical to high quality systems of healthcare delivery.

Acknowledgements

Not applicable

The rapid review is part of a larger study on global health management priorities and qualities, supported by the University of New South Wales, Sydney.

Availability of data and materials

Abbreviations, authors’ contributions.

CF conducted the database searches and identification of relevant literature. RH and AC assessed the selected literature. RH and LM conceived the design of the review and contributed to the interpretation of the review results. CF drafted the initial manuscript while RH, AC and LM reviewed and revised subsequent drafts of the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

Ethics approval and consent to participate

Consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Carah Alyssa Figueroa, Email: ua.ude.wsnu@harac .

Reema Harrison, Email: [email protected] .

Ashfaq Chauhan, Email: [email protected] .

Lois Meyer, Email: [email protected] .

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6 Common Leadership Styles — and How to Decide Which to Use When

• Rebecca Knight

Being a great leader means recognizing that different circumstances call for different approaches.

Research suggests that the most effective leaders adapt their style to different circumstances — be it a change in setting, a shift in organizational dynamics, or a turn in the business cycle. But what if you feel like you’re not equipped to take on a new and different leadership style — let alone more than one? In this article, the author outlines the six leadership styles Daniel Goleman first introduced in his 2000 HBR article, “Leadership That Gets Results,” and explains when to use each one. The good news is that personality is not destiny. Even if you’re naturally introverted or you tend to be driven by data and analysis rather than emotion, you can still learn how to adapt different leadership styles to organize, motivate, and direct your team.

Much has been written about common leadership styles and how to identify the right style for you, whether it’s transactional or transformational, bureaucratic or laissez-faire. But according to Daniel Goleman, a psychologist best known for his work on emotional intelligence, “Being a great leader means recognizing that different circumstances may call for different approaches.”

• RK Rebecca Knight is a journalist who writes about all things related to the changing nature of careers and the workplace. Her essays and reported stories have been featured in The Boston Globe, Business Insider, The New York Times, BBC, and The Christian Science Monitor. She was shortlisted as a Reuters Institute Fellow at Oxford University in 2023. Earlier in her career, she spent a decade as an editor and reporter at the Financial Times in New York, London, and Boston.

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Five Critical Challenges Facing Planning Talent & Leadership Development

This is the first in a series of blog posts based on the applied research report “Developing the Next Generation of Supply Chain Planning Talent and Leadership” by the research team of Dan Pellathy, Michael Burnette , and Ted Stank . Download the white paper .

Whether companies seek to manage complex cross-functional processes better, increase digitalization and automation, or build greater agility, planning is central to their strategic initiatives.

Given its central role, it’s not surprising that the demand for planning talent is high. However, the knowledge, skills, and attitudes that today’s planning professionals require differ from those of just a few years ago. Today, planners must be more comfortable managing ambiguity, leading change, and adapting to new technologies. At the same time, companies must be proactive in providing educational opportunities and creating processes, metrics, and incentives that build professionals’ competencies and contribute to developing tomorrow’s planning leaders.

Over the next three blog posts focusing on my recent research with GSCI’s Advanced Supply Chain Collaborative , I’ll share some of our key findings, starting with the critical challenges facing planning talent and leadership development.

The role of the supply chain planner has dramatically increased in importance within high-performance enterprises, which recognize that planning is the heart of most critical system transformations. Planners hold one of the few roles that create total value across the end-to-end business.

Recent disruptions have led companies to emphasize multifunctional business processes that require integrating individuals across different reward systems, cultures, data, and leadership. At the same time, heightened customer expectations have increased demand for customized products and services. In response, companies have increased the speed of innovation, with a corresponding increase in system complexity. More than ever, businesses are turning to planners to manage these trends.

However, organizational support for talent and leadership development has trailed behind the demands placed on the planning function. Below are five critical issues we identified in our research with partners at Pfizer, Shaw Industries, and Kenco Group that affect planners today.

#1 Changing Work Modalities

Work-from-home, hybrid, face-to-face, and other modalities present various challenges for planners. While questions of oversight and productivity are essential, the question of how best to build company culture is paramount. When associates are not integrated into a set of shared assumptions and work patterns, they lack context for communications, are less willing or able to problem-solve, and are more likely to jump to conclusions. As a result, teams can become constrained in their ability to manage operational processes while collaborating to implement needed changes to the system.

#2 Talent Need vs. Talent Availability

Available estimates suggest a significant shortfall in supply chain talent over the coming decade. Given the highly competitive market, companies must critically evaluate and dramatically overhaul their human resource practices. Talent and leadership development programs must be central to how they attract, position, and retain people in the supply chain.

High-performance organizations understand that teams with diverse experiences and knowledge make the best decisions. When people are motivated to succeed at their work, the company succeeds. Yet our discussions with industry leaders suggest that companies often fail to create systems that enable individuals to contribute to their potential. Training, promotion, career development, compensation, and reward systems must feature a long-term commitment to developing every team and individual.

Systems that create limits and ceilings must be eliminated. The planning, work, continuous improvement, and innovation cycles are collapsing exponentially. Successful companies build teams that thrive in the “new speed of business.”

#3 The Mid-Level Manager Crunch

The talent gap between entry-level and senior planning professionals is growing and presents several challenges for organizations. Entry-level planners require substantial training and acculturation before contributing in full. Training new associates is usually the responsibility of mid-level managers who are already balancing a considerable workload.

At the same time, more senior planning team members must often be reskilled. The competencies required to succeed in the planning space change rapidly. Senior members may be unfamiliar with new technologies or management styles. Without thoughtful strategies in place, the need to develop new competencies may lead to conflict within the team.

Mid-level managers are also often tasked with navigating the challenges of changing established mindsets and habits. The result can be overwhelming for them, slowing progress on critical transformations.

#4 Lack of Senior Leadership in Planning

In many organizations, planning processes are driven by quarterly decision cycles at the category level. Often, these decisions are linked to an S&OP process bogged down with difficulties in demand planning, gaps in the supply base, and cross-functional disconnects.

As a result, planning leaders have typically spent their time reacting to mismatches between an incomplete (and often outdated) plan and the operational realities facing their functional area. Planning leaders typically have not occupied senior-level positions with responsibilities tied directly to strategic initiatives.

#5 Need for Broad-Based Organization Actions & Supports

The competencies planning professionals require to be successful in the future often involve managing the social and personal dimensions of system transformations. Yet many companies continue to approach talent development through targeted activities to acquire technical skills. They have failed to combine robust educational opportunities with processes, metrics, and incentives to create broad-based experiences for growth. Companies must map current planning talent and leadership to understand their strengths and weaknesses and provide experiences for growth that align with strategic priorities. Holistic approaches are key.

In my next post, I’ll discuss in detail the core competencies and organizational action areas needed to develop good planning talent.

To learn more about how your company can partner with us to explore advanced concepts in supply chain management, visit ASCC .

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• Open access
• Published: 18 April 2024

Research ethics and artificial intelligence for global health: perspectives from the global forum on bioethics in research

• James Shaw 1 , 13 ,
• Joseph Ali 2 , 3 ,
• Caesar A. Atuire 4 , 5 ,
• Phaik Yeong Cheah 6 ,
• Armando Guio Español 7 ,
• Judy Wawira Gichoya 8 ,
• Adrienne Hunt 9 ,
• Daudi Jjingo 10 ,
• Katherine Littler 9 ,
• Daniela Paolotti 11 &
• Effy Vayena 12  

BMC Medical Ethics volume  25 , Article number:  46 ( 2024 ) Cite this article

Metrics details

The ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice. In this paper we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022.

The GFBR is an annual meeting organized by the World Health Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, research ethics committee members and other actors to engage with challenges and opportunities specifically related to research ethics. In 2022 the focus of the GFBR was “Ethics of AI in Global Health Research”. The forum consisted of 6 case study presentations, 16 governance presentations, and a series of small group and large group discussions. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. In this paper, we highlight central insights arising from GFBR 2022.

We describe the significance of four thematic insights arising from the forum: (1) Appropriateness of building AI, (2) Transferability of AI systems, (3) Accountability for AI decision-making and outcomes, and (4) Individual consent. We then describe eight recommendations for governance leaders to enhance the ethical governance of AI in global health research, addressing issues such as AI impact assessments, environmental values, and fair partnerships.

Conclusions

The 2022 Global Forum on Bioethics in Research illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research.

Peer Review reports

Introduction

The ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice [ 1 , 2 , 3 ]. Beyond the growing number of AI applications being implemented in health care, capabilities of AI models such as Large Language Models (LLMs) expand the potential reach and significance of AI technologies across health-related fields [ 4 , 5 ]. Discussion about effective, ethical governance of AI technologies has spanned a range of governance approaches, including government regulation, organizational decision-making, professional self-regulation, and research ethics review [ 6 , 7 , 8 ]. In this paper, we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health research, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022. Although applications of AI for research, health care, and public health are diverse and advancing rapidly, the insights generated at the forum remain highly relevant from a global health perspective. After summarizing important context for work in this domain, we highlight categories of ethical issues emphasized at the forum for attention from a research ethics perspective internationally. We then outline strategies proposed for research, innovation, and governance to support more ethical AI for global health.

In this paper, we adopt the definition of AI systems provided by the Organization for Economic Cooperation and Development (OECD) as our starting point. Their definition states that an AI system is “a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations, or decisions influencing real or virtual environments. AI systems are designed to operate with varying levels of autonomy” [ 9 ]. The conceptualization of an algorithm as helping to constitute an AI system, along with hardware, other elements of software, and a particular context of use, illustrates the wide variety of ways in which AI can be applied. We have found it useful to differentiate applications of AI in research as those classified as “AI systems for discovery” and “AI systems for intervention”. An AI system for discovery is one that is intended to generate new knowledge, for example in drug discovery or public health research in which researchers are seeking potential targets for intervention, innovation, or further research. An AI system for intervention is one that directly contributes to enacting an intervention in a particular context, for example informing decision-making at the point of care or assisting with accuracy in a surgical procedure.

The mandate of the GFBR is to take a broad view of what constitutes research and its regulation in global health, with special attention to bioethics in Low- and Middle- Income Countries. AI as a group of technologies demands such a broad view. AI development for health occurs in a variety of environments, including universities and academic health sciences centers where research ethics review remains an important element of the governance of science and innovation internationally [ 10 , 11 ]. In these settings, research ethics committees (RECs; also known by different names such as Institutional Review Boards or IRBs) make decisions about the ethical appropriateness of projects proposed by researchers and other institutional members, ultimately determining whether a given project is allowed to proceed on ethical grounds [ 12 ].

However, research involving AI for health also takes place in large corporations and smaller scale start-ups, which in some jurisdictions fall outside the scope of research ethics regulation. In the domain of AI, the question of what constitutes research also becomes blurred. For example, is the development of an algorithm itself considered a part of the research process? Or only when that algorithm is tested under the formal constraints of a systematic research methodology? In this paper we take an inclusive view, in which AI development is included in the definition of research activity and within scope for our inquiry, regardless of the setting in which it takes place. This broad perspective characterizes the approach to “research ethics” we take in this paper, extending beyond the work of RECs to include the ethical analysis of the wide range of activities that constitute research as the generation of new knowledge and intervention in the world.

Ethical governance of AI in global health

The ethical governance of AI for global health has been widely discussed in recent years. The World Health Organization (WHO) released its guidelines on ethics and governance of AI for health in 2021, endorsing a set of six ethical principles and exploring the relevance of those principles through a variety of use cases. The WHO guidelines also provided an overview of AI governance, defining governance as covering “a range of steering and rule-making functions of governments and other decision-makers, including international health agencies, for the achievement of national health policy objectives conducive to universal health coverage.” (p. 81) The report usefully provided a series of recommendations related to governance of seven domains pertaining to AI for health: data, benefit sharing, the private sector, the public sector, regulation, policy observatories/model legislation, and global governance. The report acknowledges that much work is yet to be done to advance international cooperation on AI governance, especially related to prioritizing voices from Low- and Middle-Income Countries (LMICs) in global dialogue.

One important point emphasized in the WHO report that reinforces the broader literature on global governance of AI is the distribution of responsibility across a wide range of actors in the AI ecosystem. This is especially important to highlight when focused on research for global health, which is specifically about work that transcends national borders. Alami et al. (2020) discussed the unique risks raised by AI research in global health, ranging from the unavailability of data in many LMICs required to train locally relevant AI models to the capacity of health systems to absorb new AI technologies that demand the use of resources from elsewhere in the system. These observations illustrate the need to identify the unique issues posed by AI research for global health specifically, and the strategies that can be employed by all those implicated in AI governance to promote ethically responsible use of AI in global health research.

RECs and the regulation of research involving AI

RECs represent an important element of the governance of AI for global health research, and thus warrant further commentary as background to our paper. Despite the importance of RECs, foundational questions have been raised about their capabilities to accurately understand and address ethical issues raised by studies involving AI. Rahimzadeh et al. (2023) outlined how RECs in the United States are under-prepared to align with recent federal policy requiring that RECs review data sharing and management plans with attention to the unique ethical issues raised in AI research for health [ 13 ]. Similar research in South Africa identified variability in understanding of existing regulations and ethical issues associated with health-related big data sharing and management among research ethics committee members [ 14 , 15 ]. The effort to address harms accruing to groups or communities as opposed to individuals whose data are included in AI research has also been identified as a unique challenge for RECs [ 16 , 17 ]. Doerr and Meeder (2022) suggested that current regulatory frameworks for research ethics might actually prevent RECs from adequately addressing such issues, as they are deemed out of scope of REC review [ 16 ]. Furthermore, research in the United Kingdom and Canada has suggested that researchers using AI methods for health tend to distinguish between ethical issues and social impact of their research, adopting an overly narrow view of what constitutes ethical issues in their work [ 18 ].

The challenges for RECs in adequately addressing ethical issues in AI research for health care and public health exceed a straightforward survey of ethical considerations. As Ferretti et al. (2021) contend, some capabilities of RECs adequately cover certain issues in AI-based health research, such as the common occurrence of conflicts of interest where researchers who accept funds from commercial technology providers are implicitly incentivized to produce results that align with commercial interests [ 12 ]. However, some features of REC review require reform to adequately meet ethical needs. Ferretti et al. outlined weaknesses of RECs that are longstanding and those that are novel to AI-related projects, proposing a series of directions for development that are regulatory, procedural, and complementary to REC functionality. The work required on a global scale to update the REC function in response to the demands of research involving AI is substantial.

These issues take greater urgency in the context of global health [ 19 ]. Teixeira da Silva (2022) described the global practice of “ethics dumping”, where researchers from high income countries bring ethically contentious practices to RECs in low-income countries as a strategy to gain approval and move projects forward [ 20 ]. Although not yet systematically documented in AI research for health, risk of ethics dumping in AI research is high. Evidence is already emerging of practices of “health data colonialism”, in which AI researchers and developers from large organizations in high-income countries acquire data to build algorithms in LMICs to avoid stricter regulations [ 21 ]. This specific practice is part of a larger collection of practices that characterize health data colonialism, involving the broader exploitation of data and the populations they represent primarily for commercial gain [ 21 , 22 ]. As an additional complication, AI algorithms trained on data from high-income contexts are unlikely to apply in straightforward ways to LMIC settings [ 21 , 23 ]. In the context of global health, there is widespread acknowledgement about the need to not only enhance the knowledge base of REC members about AI-based methods internationally, but to acknowledge the broader shifts required to encourage their capabilities to more fully address these and other ethical issues associated with AI research for health [ 8 ].

Although RECs are an important part of the story of the ethical governance of AI for global health research, they are not the only part. The responsibilities of supra-national entities such as the World Health Organization, national governments, organizational leaders, commercial AI technology providers, health care professionals, and other groups continue to be worked out internationally. In this context of ongoing work, examining issues that demand attention and strategies to address them remains an urgent and valuable task.

The GFBR is an annual meeting organized by the World Health Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, REC members and other actors to engage with challenges and opportunities specifically related to research ethics. Each year the GFBR meeting includes a series of case studies and keynotes presented in plenary format to an audience of approximately 100 people who have applied and been competitively selected to attend, along with small-group breakout discussions to advance thinking on related issues. The specific topic of the forum changes each year, with past topics including ethical issues in research with people living with mental health conditions (2021), genome editing (2019), and biobanking/data sharing (2018). The forum is intended to remain grounded in the practical challenges of engaging in research ethics, with special interest in low resource settings from a global health perspective. A post-meeting fellowship scheme is open to all LMIC participants, providing a unique opportunity to apply for funding to further explore and address the ethical challenges that are identified during the meeting.

In 2022, the focus of the GFBR was “Ethics of AI in Global Health Research”. The forum consisted of 6 case study presentations (both short and long form) reporting on specific initiatives related to research ethics and AI for health, and 16 governance presentations (both short and long form) reporting on actual approaches to governing AI in different country settings. A keynote presentation from Professor Effy Vayena addressed the topic of the broader context for AI ethics in a rapidly evolving field. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. The 2-day forum addressed a wide range of themes. The conference report provides a detailed overview of each of the specific topics addressed while a policy paper outlines the cross-cutting themes (both documents are available at the GFBR website: https://www.gfbr.global/past-meetings/16th-forum-cape-town-south-africa-29-30-november-2022/ ). As opposed to providing a detailed summary in this paper, we aim to briefly highlight central issues raised, solutions proposed, and the challenges facing the research ethics community in the years to come.

In this way, our primary aim in this paper is to present a synthesis of the challenges and opportunities raised at the GFBR meeting and in the planning process, followed by our reflections as a group of authors on their significance for governance leaders in the coming years. We acknowledge that the views represented at the meeting and in our results are a partial representation of the universe of views on this topic; however, the GFBR leadership invested a great deal of resources in convening a deeply diverse and thoughtful group of researchers and practitioners working on themes of bioethics related to AI for global health including those based in LMICs. We contend that it remains rare to convene such a strong group for an extended time and believe that many of the challenges and opportunities raised demand attention for more ethical futures of AI for health. Nonetheless, our results are primarily descriptive and are thus not explicitly grounded in a normative argument. We make effort in the Discussion section to contextualize our results by describing their significance and connecting them to broader efforts to reform global health research and practice.

Uniquely important ethical issues for AI in global health research

Presentations and group dialogue over the course of the forum raised several issues for consideration, and here we describe four overarching themes for the ethical governance of AI in global health research. Brief descriptions of each issue can be found in Table  1 . Reports referred to throughout the paper are available at the GFBR website provided above.

The first overarching thematic issue relates to the appropriateness of building AI technologies in response to health-related challenges in the first place. Case study presentations referred to initiatives where AI technologies were highly appropriate, such as in ear shape biometric identification to more accurately link electronic health care records to individual patients in Zambia (Alinani Simukanga). Although important ethical issues were raised with respect to privacy, trust, and community engagement in this initiative, the AI-based solution was appropriately matched to the challenge of accurately linking electronic records to specific patient identities. In contrast, forum participants raised questions about the appropriateness of an initiative using AI to improve the quality of handwashing practices in an acute care hospital in India (Niyoshi Shah), which led to gaming the algorithm. Overall, participants acknowledged the dangers of techno-solutionism, in which AI researchers and developers treat AI technologies as the most obvious solutions to problems that in actuality demand much more complex strategies to address [ 24 ]. However, forum participants agreed that RECs in different contexts have differing degrees of power to raise issues of the appropriateness of an AI-based intervention.

The second overarching thematic issue related to whether and how AI-based systems transfer from one national health context to another. One central issue raised by a number of case study presentations related to the challenges of validating an algorithm with data collected in a local environment. For example, one case study presentation described a project that would involve the collection of personally identifiable data for sensitive group identities, such as tribe, clan, or religion, in the jurisdictions involved (South Africa, Nigeria, Tanzania, Uganda and the US; Gakii Masunga). Doing so would enable the team to ensure that those groups were adequately represented in the dataset to ensure the resulting algorithm was not biased against specific community groups when deployed in that context. However, some members of these communities might desire to be represented in the dataset, whereas others might not, illustrating the need to balance autonomy and inclusivity. It was also widely recognized that collecting these data is an immense challenge, particularly when historically oppressive practices have led to a low-trust environment for international organizations and the technologies they produce. It is important to note that in some countries such as South Africa and Rwanda, it is illegal to collect information such as race and tribal identities, re-emphasizing the importance for cultural awareness and avoiding “one size fits all” solutions.

The third overarching thematic issue is related to understanding accountabilities for both the impacts of AI technologies and governance decision-making regarding their use. Where global health research involving AI leads to longer-term harms that might fall outside the usual scope of issues considered by a REC, who is to be held accountable, and how? This question was raised as one that requires much further attention, with law being mixed internationally regarding the mechanisms available to hold researchers, innovators, and their institutions accountable over the longer term. However, it was recognized in breakout group discussion that many jurisdictions are developing strong data protection regimes related specifically to international collaboration for research involving health data. For example, Kenya’s Data Protection Act requires that any internationally funded projects have a local principal investigator who will hold accountability for how data are shared and used [ 25 ]. The issue of research partnerships with commercial entities was raised by many participants in the context of accountability, pointing toward the urgent need for clear principles related to strategies for engagement with commercial technology companies in global health research.

The fourth and final overarching thematic issue raised here is that of consent. The issue of consent was framed by the widely shared recognition that models of individual, explicit consent might not produce a supportive environment for AI innovation that relies on the secondary uses of health-related datasets to build AI algorithms. Given this recognition, approaches such as community oversight of health data uses were suggested as a potential solution. However, the details of implementing such community oversight mechanisms require much further attention, particularly given the unique perspectives on health data in different country settings in global health research. Furthermore, some uses of health data do continue to require consent. One case study of South Africa, Nigeria, Kenya, Ethiopia and Uganda suggested that when health data are shared across borders, individual consent remains necessary when data is transferred from certain countries (Nezerith Cengiz). Broader clarity is necessary to support the ethical governance of health data uses for AI in global health research.

Recommendations for ethical governance of AI in global health research

Dialogue at the forum led to a range of suggestions for promoting ethical conduct of AI research for global health, related to the various roles of actors involved in the governance of AI research broadly defined. The strategies are written for actors we refer to as “governance leaders”, those people distributed throughout the AI for global health research ecosystem who are responsible for ensuring the ethical and socially responsible conduct of global health research involving AI (including researchers themselves). These include RECs, government regulators, health care leaders, health professionals, corporate social accountability officers, and others. Enacting these strategies would bolster the ethical governance of AI for global health more generally, enabling multiple actors to fulfill their roles related to governing research and development activities carried out across multiple organizations, including universities, academic health sciences centers, start-ups, and technology corporations. Specific suggestions are summarized in Table  2 .

First, forum participants suggested that governance leaders including RECs, should remain up to date on recent advances in the regulation of AI for health. Regulation of AI for health advances rapidly and takes on different forms in jurisdictions around the world. RECs play an important role in governance, but only a partial role; it was deemed important for RECs to acknowledge how they fit within a broader governance ecosystem in order to more effectively address the issues within their scope. Not only RECs but organizational leaders responsible for procurement, researchers, and commercial actors should all commit to efforts to remain up to date about the relevant approaches to regulating AI for health care and public health in jurisdictions internationally. In this way, governance can more adequately remain up to date with advances in regulation.

Second, forum participants suggested that governance leaders should focus on ethical governance of health data as a basis for ethical global health AI research. Health data are considered the foundation of AI development, being used to train AI algorithms for various uses [ 26 ]. By focusing on ethical governance of health data generation, sharing, and use, multiple actors will help to build an ethical foundation for AI development among global health researchers.

Third, forum participants believed that governance processes should incorporate AI impact assessments where appropriate. An AI impact assessment is the process of evaluating the potential effects, both positive and negative, of implementing an AI algorithm on individuals, society, and various stakeholders, generally over time frames specified in advance of implementation [ 27 ]. Although not all types of AI research in global health would warrant an AI impact assessment, this is especially relevant for those studies aiming to implement an AI system for intervention into health care or public health. Organizations such as RECs can use AI impact assessments to boost understanding of potential harms at the outset of a research project, encouraging researchers to more deeply consider potential harms in the development of their study.

Fourth, forum participants suggested that governance decisions should incorporate the use of environmental impact assessments, or at least the incorporation of environment values when assessing the potential impact of an AI system. An environmental impact assessment involves evaluating and anticipating the potential environmental effects of a proposed project to inform ethical decision-making that supports sustainability [ 28 ]. Although a relatively new consideration in research ethics conversations [ 29 ], the environmental impact of building technologies is a crucial consideration for the public health commitment to environmental sustainability. Governance leaders can use environmental impact assessments to boost understanding of potential environmental harms linked to AI research projects in global health over both the shorter and longer terms.

Fifth, forum participants suggested that governance leaders should require stronger transparency in the development of AI algorithms in global health research. Transparency was considered essential in the design and development of AI algorithms for global health to ensure ethical and accountable decision-making throughout the process. Furthermore, whether and how researchers have considered the unique contexts into which such algorithms may be deployed can be surfaced through stronger transparency, for example in describing what primary considerations were made at the outset of the project and which stakeholders were consulted along the way. Sharing information about data provenance and methods used in AI development will also enhance the trustworthiness of the AI-based research process.

Sixth, forum participants suggested that governance leaders can encourage or require community engagement at various points throughout an AI project. It was considered that engaging patients and communities is crucial in AI algorithm development to ensure that the technology aligns with community needs and values. However, participants acknowledged that this is not a straightforward process. Effective community engagement requires lengthy commitments to meeting with and hearing from diverse communities in a given setting, and demands a particular set of skills in communication and dialogue that are not possessed by all researchers. Encouraging AI researchers to begin this process early and build long-term partnerships with community members is a promising strategy to deepen community engagement in AI research for global health. One notable recommendation was that research funders have an opportunity to incentivize and enable community engagement with funds dedicated to these activities in AI research in global health.

Seventh, forum participants suggested that governance leaders can encourage researchers to build strong, fair partnerships between institutions and individuals across country settings. In a context of longstanding imbalances in geopolitical and economic power, fair partnerships in global health demand a priori commitments to share benefits related to advances in medical technologies, knowledge, and financial gains. Although enforcement of this point might be beyond the remit of RECs, commentary will encourage researchers to consider stronger, fairer partnerships in global health in the longer term.

Eighth, it became evident that it is necessary to explore new forms of regulatory experimentation given the complexity of regulating a technology of this nature. In addition, the health sector has a series of particularities that make it especially complicated to generate rules that have not been previously tested. Several participants highlighted the desire to promote spaces for experimentation such as regulatory sandboxes or innovation hubs in health. These spaces can have several benefits for addressing issues surrounding the regulation of AI in the health sector, such as: (i) increasing the capacities and knowledge of health authorities about this technology; (ii) identifying the major problems surrounding AI regulation in the health sector; (iii) establishing possibilities for exchange and learning with other authorities; (iv) promoting innovation and entrepreneurship in AI in health; and (vi) identifying the need to regulate AI in this sector and update other existing regulations.

Ninth and finally, forum participants believed that the capabilities of governance leaders need to evolve to better incorporate expertise related to AI in ways that make sense within a given jurisdiction. With respect to RECs, for example, it might not make sense for every REC to recruit a member with expertise in AI methods. Rather, it will make more sense in some jurisdictions to consult with members of the scientific community with expertise in AI when research protocols are submitted that demand such expertise. Furthermore, RECs and other approaches to research governance in jurisdictions around the world will need to evolve in order to adopt the suggestions outlined above, developing processes that apply specifically to the ethical governance of research using AI methods in global health.

Research involving the development and implementation of AI technologies continues to grow in global health, posing important challenges for ethical governance of AI in global health research around the world. In this paper we have summarized insights from the 2022 GFBR, focused specifically on issues in research ethics related to AI for global health research. We summarized four thematic challenges for governance related to AI in global health research and nine suggestions arising from presentations and dialogue at the forum. In this brief discussion section, we present an overarching observation about power imbalances that frames efforts to evolve the role of governance in global health research, and then outline two important opportunity areas as the field develops to meet the challenges of AI in global health research.

Dialogue about power is not unfamiliar in global health, especially given recent contributions exploring what it would mean to de-colonize global health research, funding, and practice [ 30 , 31 ]. Discussions of research ethics applied to AI research in global health contexts are deeply infused with power imbalances. The existing context of global health is one in which high-income countries primarily located in the “Global North” charitably invest in projects taking place primarily in the “Global South” while recouping knowledge, financial, and reputational benefits [ 32 ]. With respect to AI development in particular, recent examples of digital colonialism frame dialogue about global partnerships, raising attention to the role of large commercial entities and global financial capitalism in global health research [ 21 , 22 ]. Furthermore, the power of governance organizations such as RECs to intervene in the process of AI research in global health varies widely around the world, depending on the authorities assigned to them by domestic research governance policies. These observations frame the challenges outlined in our paper, highlighting the difficulties associated with making meaningful change in this field.

Despite these overarching challenges of the global health research context, there are clear strategies for progress in this domain. Firstly, AI innovation is rapidly evolving, which means approaches to the governance of AI for health are rapidly evolving too. Such rapid evolution presents an important opportunity for governance leaders to clarify their vision and influence over AI innovation in global health research, boosting the expertise, structure, and functionality required to meet the demands of research involving AI. Secondly, the research ethics community has strong international ties, linked to a global scholarly community that is committed to sharing insights and best practices around the world. This global community can be leveraged to coordinate efforts to produce advances in the capabilities and authorities of governance leaders to meaningfully govern AI research for global health given the challenges summarized in our paper.

Limitations

Our paper includes two specific limitations that we address explicitly here. First, it is still early in the lifetime of the development of applications of AI for use in global health, and as such, the global community has had limited opportunity to learn from experience. For example, there were many fewer case studies, which detail experiences with the actual implementation of an AI technology, submitted to GFBR 2022 for consideration than was expected. In contrast, there were many more governance reports submitted, which detail the processes and outputs of governance processes that anticipate the development and dissemination of AI technologies. This observation represents both a success and a challenge. It is a success that so many groups are engaging in anticipatory governance of AI technologies, exploring evidence of their likely impacts and governing technologies in novel and well-designed ways. It is a challenge that there is little experience to build upon of the successful implementation of AI technologies in ways that have limited harms while promoting innovation. Further experience with AI technologies in global health will contribute to revising and enhancing the challenges and recommendations we have outlined in our paper.

Second, global trends in the politics and economics of AI technologies are evolving rapidly. Although some nations are advancing detailed policy approaches to regulating AI more generally, including for uses in health care and public health, the impacts of corporate investments in AI and political responses related to governance remain to be seen. The excitement around large language models (LLMs) and large multimodal models (LMMs) has drawn deeper attention to the challenges of regulating AI in any general sense, opening dialogue about health sector-specific regulations. The direction of this global dialogue, strongly linked to high-profile corporate actors and multi-national governance institutions, will strongly influence the development of boundaries around what is possible for the ethical governance of AI for global health. We have written this paper at a point when these developments are proceeding rapidly, and as such, we acknowledge that our recommendations will need updating as the broader field evolves.

Ultimately, coordination and collaboration between many stakeholders in the research ethics ecosystem will be necessary to strengthen the ethical governance of AI in global health research. The 2022 GFBR illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research.

Data availability

All data and materials analyzed to produce this paper are available on the GFBR website: https://www.gfbr.global/past-meetings/16th-forum-cape-town-south-africa-29-30-november-2022/ .

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Acknowledgements

We would like to acknowledge the outstanding contributions of the attendees of GFBR 2022 in Cape Town, South Africa. This paper is authored by members of the GFBR 2022 Planning Committee. We would like to acknowledge additional members Tamra Lysaght, National University of Singapore, and Niresh Bhagwandin, South African Medical Research Council, for their input during the planning stages and as reviewers of the applications to attend the Forum.

This work was supported by Wellcome [222525/Z/21/Z], the US National Institutes of Health, the UK Medical Research Council (part of UK Research and Innovation), and the South African Medical Research Council through funding to the Global Forum on Bioethics in Research.

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Caesar A. Atuire

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JS led the writing, contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. JA contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. CA contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. PYC contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. AE contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. JWG contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. AH contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. DJ contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. KL contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. DP contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper. EV contributed to conceptualization and analysis, critically reviewed and provided feedback on drafts of this paper, and provided final approval of the paper.

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Shaw, J., Ali, J., Atuire, C.A. et al. Research ethics and artificial intelligence for global health: perspectives from the global forum on bioethics in research. BMC Med Ethics 25 , 46 (2024). https://doi.org/10.1186/s12910-024-01044-w

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DOI : https://doi.org/10.1186/s12910-024-01044-w

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