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Entrepreneurial Leadership and Innovation Performance in New Ventures: Examining the Roles of Strategic Flexibility and Environmental Turbulence

This study seeks to disclose the influencing mechanism of entrepreneurial leadership on innovation performance in new ventures. Drawing on the upper echelons theory, we construct a mediation model to examine the mechanism through which entrepreneurial leadership affects innovation performance of new ventures via strategic flexibility. To obtain an in-depth understanding of the mediating mechanism, this study argues that environmental turbulence could be considered as the moderating variable. Our hypotheses are tested on a sample of 175 Chinese high-tech new ventures. The results show that strategic flexibility mediates the association between entrepreneurial leadership and innovation performance. However, the results only support the moderation of technological turbulence on the association between entrepreneurial leadership and strategic flexibility. Our findings extend the entrepreneurship and leadership research by investigating how entrepreneurial leadership affects innovation performance of new ventures via strategic flexibility, and the effectiveness of entrepreneurial leadership under technological turbulence.

Funding source: National Social Science Foundation of China

Award Identifier / Grant number: 19CRK021

Funding source: Philosophy and Social Science Program of Shanghai City

Award Identifier / Grant number: 2019EGL020

Award Identifier / Grant number: 2018BSH006

Funding source: Humanities and Social Sciences Program of Chinese Ministry of Education

Award Identifier / Grant number: 18YJA79011

Research funding: This work was supported by the National Social Science Foundation of China (No. 19CRK021), Philosophy and Social Science Program of Shanghai City (No. 2019EGL020), Philosophy and Social Science Program of Shanghai City (No. 2018BSH006) and Humanities and Social Sciences Program of Chinese Ministry of Education (No. 18YJA79011).

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Entrepreneurial Leadership and Entrepreneurial Success: The Role of Knowledge Management Processes and Knowledge Entrepreneurship

Nida hussain.

1 Business School, Zhengzhou University, Zhengzhou, China

2 Yunus Social Business Center, Zhengzhou University, Zhengzhou, China

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The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Various leadership styles have been widely studied to understand success. However, little research has empirically explored how entrepreneurial leadership (EL) influences entrepreneurial success (ES). Moreover, the role of knowledge management processes (KMPs) and knowledge entrepreneurship (KE) have been overlooked. Thus, using a knowledge-based view theory, this study aims to determine the relationship between EL and ES, mediated through KMPs. In addition, for a better understanding, the study also used KE as a moderator. A quantitative survey method has been employed to collect data from 390 entrepreneurial venture (EV) owners, co-founders, and managers in tech-oriented ventures (IT and Software-based) operating in Pakistan. Smart partial least squares (PLS) statistical software was used to analyze the impact mechanism of EL on ES through the structural equation model. The findings revealed that EL style positively influences ES. In addition, KMPs fully mediate the relationship between EL and ES. Furthermore, KE as a moderator, strengthens the relationships between EL and the knowledge management process. Theoretically, this study has complemented and enriched research on the influence mechanism between EL and ES. Practically, this study has important implications for leaders, managers, and founders to promote KMPs to achieve ES.

Introduction

Leaders are usually known for their continual learning behavior that help them to sustain and achieve desired objectives in the form of success ( Villaluz and Hechanova, 2019 ). Consequently, leadership styles vary from person to person. Entrepreneurial leadership (EL) is an association with passion for innovation, risk-taking ability, decision-making, and proactiveness ( Gupta et al., 2004 ; Harrison et al., 2016 ; Al Mamun et al., 2018 ). The evolving EL style has extended its domain in firm enactment, venture success, and managerial development. EL has its role in refining organizational performance, which involves the pro-activeness, innovativeness, and risk-taking abilities of entrepreneurs ( Dwi Widyani et al., 2020 ). It is pertinent to mention that EL is not a new paradigm ( Huang et al., 2014 ; Leitch and Volery, 2017 ). The pivotal aspect of EL is to execute innovative ideas and business ventures ( Leitch and Volery, 2017 ). In addition, the roadmap followed by EL is often full of uncertainties and risks, therefore, numerous strategies and approaches are adopted by EL to make their business successful ( Hodgetts and Kuratko, 2004 ). Furthermore, EL provides opportunities to team members operating in different domains to foster entrepreneurial success (ES) ( Huang et al., 2014 ; Alshanty and Emeagwali, 2019 ).

Entrepreneurial success has been acknowledged as a vital factor by entrepreneurs. ES is reported as a significant phenomenon for entrepreneurial perception ( Fisher et al., 2014 ). Yet, this phenomenon of ES is frequently understood by the realization of a successful entrepreneurial venture (EV) ( Staniewski and Awruk, 2019 ), and is sometimes associated with personal success. However, the research claims that success is further achieved through identifying leadership styles ( Arham et al., 2017 ). Thus, a diverse leadership style contributes toward ES. Additionally, current theoretical and empirical studies reveal that a great variety of leadership styles influence successful business ventures and ES ( Bertoldi, 2021 ). McKenzie and Sud (2008) discussed that the ultimate ES could learn from entrepreneurial failure. Baron and Henry (2011) suggested that ES cannot be calculated in monetary growth, it is associated with knowledge and implementation of different methods to attract investors toward business. Furthermore, success also counts as long term sustainability in the market. It is linked with other key drivers that help entrepreneurs step toward ES. Moreover, Visser et al. (2005) understand the relationship of transformational leadership through success. This study also stated that entrepreneurship could have a significant positive relationship with success. However, key functions of entrepreneurship as a subcategory of transformational leadership were still unclear. Entrepreneurial behavior also impacts the growth and success of an EV ( Elia et al., 2020 ).

According to a research article published by Murphy (1992) , technical training and workshops enhance the performance of leaders in terms of success. It has been suggested that leadership skill training plays an essential role in making an individual more capable, confident, and productive ( IMD Leadership, 2021 ). On the other hand, entrepreneurs are risk-takers ( Donbesuur et al., 2020 ), innovators ( Thomas and Mueller, 2000 ), and competitors ( Ali et al., 2020 ) in the comparative market. Therefore, such natural qualities and training polish EL hidden strengths that help them to achieve more success. However, leaders have persistent affection for knowledge management processes (KMPs) to venture execution and operations ( Singh, 2008 ). Thus, in the context of a knowledge base view (KBV) theory by Grant (1996) mentioned that if any organization utilizes and implants the knowledge effectively and efficiently, it can lead, compete, take leverage in the competitive market. Shujahat et al. (2019) studied KBV and presumed that KMP (processes include knowledge conversion, acquisition, creation, protection, sharing, and utilization) plays a notable role in competitive advantage and improving performance. Another study shows that EL can be an essential and useful mechanism for knowledge sharing (KS) inside a business venture to take proper and rational decisions ( Dirani et al., 2020 ). Numerous industries have recognized the implementation and incentive significance of KMP because the vitality of entrepreneurial orientation in a business venture depends on the amplitude of the implemented KMP ( Latif et al., 2020 ).

García-Álvarez (2015) discussed a thorough strategy to make the right knowledge available at an accurate time. Hence, available and correct knowledge aids people to make precise decisions. Furthermore, accurate knowledge increases business competitiveness, which helps in ES. Abd Rahman et al. (2013) also argue about the response of KMP on the team skills and improvement of their business. Various research demonstrates that KMP plays a vital role in anticipation of individual capabilities toward the adoption of knowledge ( Liao et al., 2007 ; Yeşil and Dereli, 2013 ).

Knowledge is considered a foremost manifestation of ES ( Roxas et al., 2009 ). Knowledge entrepreneurship (KE) reflect innovation in any business ( McDonald, 2002 ). Term KE is associated to identify the functions of entrepreneurship to the pipeline process in a proper way ( Landström et al., 2012 ). According to McDonald (2002) , it consists of four dimensions, including knowledge about environmental issues, conscientiousness in performing duties, a pledge to new projects, and acceptance of risky situations. However, with innovation, entrepreneurs mostly cooperate on these four dimensions. It is also stated that the ability of an organization to recognize new or existing knowledge as valuable, and as something to react to or exploit through the adoption of innovation ( McDonald, 2002 ). Fernandes et al. (2017) , reveals different factors as influential for KE, including detection of capabilities, entrepreneurial experience, and experience investing in other firms. Furthermore, the settings adopted by leadership are set to determine the general possibilities for KE to occur ( Audretsch and Keilbach, 2007 ; Michelini, 2008 ). Thereby, the knowledge setting signifies the basic facts of the EV, such as its size, type of institution, business model, history, and historic approach to innovation. Under leadership, the style and values embraced by the current top decision makers, as well as the governance structure itself are evaluated ( Cleveland and Cleveland, 2020 ; Bhatti et al., 2021 ). Thus, the concept of KE by a leader is central to the understanding of enabling or discouraging the conditions of business, as it adapts its attitude toward learning and whether values like innovativeness, competitiveness, and entrepreneurship, etc., are embraced or rejected ( Leadbeater and Oakley, 2001 ; McDonald, 2002 ; Hayter, 2013 ).

Previous studies have only focused on EL styles influenced on the organization or firm performance ( Nguyen et al., 2021 ), employee behavior ( Bagheri, 2017 ), employee creativity ( Newman et al., 2018 ), and workplace creativity ( Cai et al., 2019 ). However, it was suggested that a relationship between EL and ES should be established ( Viswanathan et al., 2014 ; Renko et al., 2015 ). It is noteworthy that limited literature is available in the domains of EL and ES. Thus, researchers need to pay more consideration to contribute in the area of EL in business studies ( Al Mamun et al., 2018 ). Concerns have arisen about the relationship between EL and ES. Furthermore, knowledge management is considered one of the key drivers for ES ( Gaimon and Bailey, 2013 ). Knowledge management is linked with intellectual capital and high tech EVs. Additionally, KS is considered a key element of success ( Oliveira et al., 2020 ). However, a gap in KMPs needs to be addressed: mediation ( Yao et al., 2020 ; Zahedi and Naghdi Khanachah, 2021 ). It has now been suggested that the role of KMP as a mediator should be validated, which could explicate the influence of leadership on distinct operational levels in business to achieve success ( Soto-Acosta et al., 2018 ; Martins et al., 2019 ). Furthermore, the role of KE as a moderator has been rarely studied ( McDonald, 2002 ; Kamal et al., 2020 ).

In recent years there has been considerable interest in leadership styles such as transformational leadership, transactional leadership, and paternalistic leadership style ( Sorenson, 2000 ; Nogueira et al., 2018 ; Raziq et al., 2018 ), as a foundation of success. The relationship between leadership and success is studied, unlike with various mediating and moderating variables ( Boga and Ensari, 2009 ; Elche et al., 2020 ; Muliati, 2020 ). This study identifies the knowledge gaps and employs them to contribute to literature and knowledge on EL by probing its implications for KMPs toward ES. Therefore, the following research is among the first to consider EL as a significant antecedent of ES. The research explores whether EL can act as an effective forecaster of KMPs. With this research, the quality of literature on KMP has been raised which is advantageous to recognize the role of KMPs in the progress of ES. Additionally, it subsidizes the literature related to leadership as it evaluated the novel practice of various leadership styles and KMPs, KE, and ES are rarely studied ( Gupta et al., 2004 ; Renko et al., 2015 ; Dwivedi et al., 2020 ; Li et al., 2020 ). Hence, this research will deliver auxiliary perceptions to KBV theory by indicating how EL supports KMP toward ES and how EL support KMPs under the moderating effect of KE toward ES.

To the best of our knowledge, few research articles have explored the impact of EL on KMPs ( Shamim et al., 2019 ). Hence under the consideration of KBV, the analysis will give insights into information by showing how EL supports KMPs that result in ES. The considering mechanism will assist to understand the EL effects on the ES. Moreover, the moderating role of KE will help to understand the relationship between EL and KMPs toward ES. KE is associated with up-to-date market trends. Such knowledge-based trends help entrepreneurs to evaluate their ventures in a more meaningful way. However, the KE environment is usually ignored by Pakistani entrepreneurs toward success. Hence, the following research focused on KBV ( Cabrera-Suárez et al., 2001 ; Grant, 2013 ) to study the proposed research model under the context of Pakistani entrepreneurs. This research aimed to investigate the impact of EL on ES under the mediation of KMPs and moderation of KE on EL and KMPs toward ES in Pakistani on Tech-oriented business venture (Software/IT based companies). Based on the importance of EL, ES, KMPs, and KE, this study aims to identify the gaps in existing research. Therefore, the following research questions were proposed:

• RQ1: Is there any direct impact of EL on ES in tech-oriented ventures in Pakistan?
• RQ2: Do KMPs mediate the relationship between EL and ES in tech-oriented ventures in Pakistan?
• RQ3: Does KE moderate the relationship between EL and KMP toward success in tech-oriented ventures in Pakistan?

The following paper is structured in six sections. Section “Literature Review” focuses on a detailed literature review. Section “Theory and Hypothesis Development” describes the theoretical framework and hypothesis development. Section “Methodology” defines the methodology, while section “Discussion” presents the results and discussion of the study. Finally, section “Conclusion” presents the conclusion, implications, and future research directions.

Literature Review

Entrepreneurial leadership.

Fløistad (1991) defined EL as a source of opportunity that revolves around achieving goals, creating chances in the job market and developing an environment for empowering people. EL can be differentiated among leadership and non-leadership skills, specifically entrepreneurial risk-taking behavior and innovative openness ( Nicholas, 1998 ). Conversely, Gupta et al. (2004) refer to EL as “leadership that creates visionary scenarios that are used to assemble and mobilize a ‘supporting cast’ of participants who become committed by the vision to the discovery and exploitation of strategic value creation.” EL also creates the ability among individuals to identify the opportunities or market gaps, innovations, and solutions to comparative markets ( Ireland et al., 2003 ). The vigorous visionary processes and creative features of entrepreneurship are discussed further in various studies ( Kuratko, 2006 ). Furthermore, EL as a potential creator refers to a vision and mission that inspires and guides employees (followers) to make efforts and achieve set goals ( Gupta et al., 2019 ). Therefore, EL requires determination to bring solutions for challenges, reduce uncertainty and risk in various stages of venture development.

Leaders are authorized to coordinate meritoriously inside an organization and solve challenging issues to improve and develop EVs ( Aga et al., 2016 ). Different leadership styles are evident in entrepreneurial and transformational leadership ( Pan et al., 2021 ). Transformational leaders focus on encouraging followers to achieve both corporate and personal goals ( Zaman et al., 2020 ). Individualized attention is essential to transformational leadership, but it is not a component of EL. Contingent reward offers followers assistance in achieving self-actualization in transformational leadership ( Al-Ghazali, 2020 ). Transformational and transactional leadership styles are portrayed as a person entrusted with an organizational task that must be completed within a certain organizational environment ( Gupta et al., 2004 ). EL has to deal with new ideas and concepts which are not limited to an organizational level. Therefore, EL character should be more visionary, risk-taking, problem-solving, and involve strong decision making and strategic initiative ( Renko et al., 2015 ). EL is perhaps not labeled as charismatic and inspirational as often as transformational leaders, even though they have principals with clear determination and objectives ( Podsakoff et al., 1990 ). In addition, team-oriented leadership emphasizes efficient communication and collaboration, situational resolving, and interpersonal and group connections ( Gupta et al., 2004 ). However, EL stresses route clearing for opportunity exploitation and value development.

Scholars have stated that leaders are supposed to be entrepreneurs ( Czarniawska-Joerges and Wolff, 1991 ; Shane, 2010 ; Hubner, 2020 ). According to Henry et al. (2015) , EL is a new level of leadership performance with high potential to bring novel change in the market. Hence, it enhances the performance of employees toward venture success and plays a vital role in any venture execution. EL provides a comparative advantage to innovative and newly discovered opportunities ( Phangestu et al., 2020 ). EL assist individual to be successful leader, by solving critical problems and risk-taking abilities. Various arguments also lead that EL creates opportunities for materializing an innovative atmosphere for achieving goals ( Si et al., 2015 ). EVs are developed with specialized leadership. Leaders undertake the development and maintain a profitable venture ( Birley and Stockley, 2017 ). EL is a distinctive leadership style. Mainly concentrated on utilizing heterogeneous abilities to operate resourcefully and inventively in a competitive environment ( Musa and Fontana, 2016 ). Gupta et al. (2004) outline that EL is acknowledged extensively around the globe and is most acceptable in the western world.

Knowledge Management Processes

In the modern era knowledge is the most valuable asset for any organization. Primarily, Drucker (2012) specifies that raw material, products or services, available data or human minds are the basic source of knowledge industries. Nevertheless, these are the pivots for any organization or firm in order to perform tasks. Additional, knowledge creates market leverage with innovations and transforms ( Maruf and Zhou, 2015 ). Jain (2007) intentionally recognized KMPs as an effective process of creating, storing, transforming, and sharing both learned and articulated knowledge to achieve required goals. Masa’deh et al. (2019) differentiated knowledge distribution outlining that it should be accurately divided and properly delivered to the right person at the right time to increase efficiency.

KM enabler permits leadership association with different organizations, to align KM behaviors with efficient strategies, policies, opportunities, effective communication, and enable learning processes ( Yeh et al., 2006 ). Knowledge management endorses the values and offers metrics for determining knowledge influence in an organization. Consequently, leadership takes into account strategic challenges that help top level management consume available knowledge resources to upgrade competencies ( Chin Wei et al., 2009 ). Moreover, acceptance of modern KS methods in an organization develops innovative and creative abilities in individuals. KMPs are a process by which a company creates, shares, uses, and manages knowledge. It is referred to a multidisciplinary approach that makes the best use of knowledge to achieve organizational goals. Hence, KMPs is an organizational learning facilitator ( Jang et al., 2002 ; du Plessis, 2007 ).

According to Sadeghi and Rad (2018) , knowledge acquisition (KA), KS, knowledge storage (KST), and knowledge applications (KAPP) are four major processes of KMP. KA refers to a process of retrieving, standardizing, and sorting information from a single source ( Feroz et al., 2021 ). It practically initiates the venture to identify the market gap and opportunities to collect critical data from external extreme sources ( Sousa and Rocha, 2019 ). KST is mentioned as a modern tool to store, sort, and organize available and collected data ( Chou, 2005 ). KS confers the activity of sharing knowledge within an organization or customers according to their requirements ( Wang and Noe, 2010 ). KAPP is defined as the effective and efficient use of available market, customer and competitor related data that helps in the achievement of desired objectives ( Derek Ajesam et al., 2007 ). Utilizing KMPs accurately according to comparative knowledge provides an opportunity for organizations in which they can achieve their targeted desired goals and success ( Obeidat et al., 2016 ). The pioneering work of Nonaka (1994) “ The knowledge-creating company ,” discusses how Japanese firms created innovation based on knowledge. The study uses Polanyi’s conception of “ tacit knowledge ” and cultivates a set of practical observations known as the SECI approach ( Socialization , Externalization , Combination , and Internationalization ). Under this approach knowledge is explicit and vice-versa ( Nonaka et al., 1996 , 2006 ; Durst and Runar Edvardsson, 2012 ).

Knowledge Entrepreneurship

Knowledge entrepreneurship is a new concept. Initially, researchers define knowledge and entrepreneurship as individual entities. However, McKnight and Chervany (2001) state that an individual with the competence of knowledge and skill can implement various processes to execute a venture. KE refers to an ability that identifies an opportunity to comprehend an influential impactful product or service ( Leadbeater and Oakley, 2001 ). KE differs from “traditional” entrepreneurial definitions, KE focuses on opportunities with improvement in knowledge creation and dissemination rather than monetary benefit ( Ossai and Iwegbu, 2012 ). KE refers to aptitude by identifying a paradigm as an opportunity for taking action and intends to recognize innovative knowledge practice ( Izzrech et al., 2013 ).

“Surfing the Long Wave: Knowledge Entrepreneurship in Britain” was a report that aimed to influence policy planning in the United Kingdom ( Leadbeater and Oakley, 2001 ). This report was designated that “the entrepreneur is starting an enterprise that is based on knowledge work.” Though, this report was initial to start comments on KE. It was recommended by McDonald (2002) that KE is associated with innovation that leads any business, organization, or firm toward better performance: increasing KE mindsets increases innovation. Later, Coulson-Thomas (2003) discussed how knowledge-based opportunities (KBO) are diverse from resource-based opportunities (RBO). According to the author skill of acquiring, storing, sorting, and sharing exploited knowledge among team members is the first step toward success.

Skrzeszewski (2006) defines KE as an individual with skills and implementing skillsets on intellectual assets for new venture creations. With sufficient personal professional knowledge, an individual can generate value, profit, and opportunities. Furthermore, he argues that “The knowledge entrepreneur must know more about the subject at hand than his/her client or boss. It does not always have to be a great deal; sometimes the difference is based on the ability to communicate, present, or more importantly, apply the knowledge asset” (p. 3). However, Senges (2007) used McDonald’s (2002) model to propose the set of factors that directly shape the KE ability.

Researchers have also examined how entrepreneurial knowledge includes scanning, opportunity selection, strategy development, and association with management and leadership, which are interrelated tasks ( Shane and Venkataraman, 2000 ; Chou, 2005 ; Singh, 2008 ; Unger et al., 2011 ). Anderson and Miller (2003) associated the different characteristics of human capital with entrepreneurial knowledge. They state that functional and theoretical knowledge are both important for understanding entrepreneurial awareness.

Entrepreneurial Success

Entrepreneurial success is a complex phenomenon. Researchers argue that monetary or non-monetary factors can be a source of ES. Usually, ES is associated with venture success. Scholars have also stated that both entrepreneurial and venture success is the same ( Bamford et al., 2004 ; Hogarth and Karelaia, 2012 ). In the end, entrepreneurs are focused on how they make themself and their venture successful. Some researchers also identified that gender inequality affects performance expectations and success. Men consider objective criteria to define success, such as obtaining prominence or acknowledgment of accomplishments, while women use intrinsic criteria to measure how they achieved their goals ( Cliff, 1998 ; Burger-Helmchen, 2008 ). A metric of ES may help to identify actual and future successful ventures, as well as strengthen public policy aimed at increasing the success rate of a new venture ( Fried and Tauer, 2009 ). Sometimes individuals also have strong willpower, which helps them to utilize resources effectively, reduce the extra cost to achieve success, and minimize entrepreneurial failure ( Caliendo and Kritikos, 2008 ).

Entrepreneurial success is associated practically with economic or financial parameters ( Zhou et al., 2019 ). Further, ES refers to strength and determination which endure the process of business execution and its remaining segments in the market for long run ( Fisher et al., 2014 ). Only limiting ES with economic or financial indicators are not enough to understand the subjective criteria ( Hogarth and Karelaia, 2012 ; Sarasvathy et al., 2013 ). Alstete (2008) shows that it i not necessary to associate ES with wealth but some associate it with work-life balance, this is mostly related to women entrepreneurs ( Orlandi, 2017 ) case studies. Thus, for social entrepreneurship capital growth might not be a measure of success ( Austin et al., 2006 ). However, substitute value creation and impactful activities are considered as supporting indicators to measure success ( Thompson, 2004 ; Edelman et al., 2008 ). Therefore, ES is mostly associated with venture success.

When scholars argue about entrepreneurial opportunities, gaps or behavior toward success these arguments vary from researcher to researcher. Shane and Venkataraman (2000) suggested essential question for entrepreneurial researchers is “ Why, when, and how some people and not others discover and exploit opportunities .” However, some argue about entrepreneurial behavior help entrepreneurs to grow and become successful ( Mitchelmore and Rowley, 2010 ). EV success factors are associated with the opportunities availed by entrepreneurs ( Renko et al., 2015 ). Entrepreneurship opportunity means a situation favorable for the success of EV. Every ES depends upon understanding the market situation, creativity, and growth opportunity. Moreover, leadership style holds a strong influence on success.

Theory and Hypothesis Development

Knowledge base view.

Knowledge base view identifies knowledge as a significant firm or business resource, it recognizes it as a strategic and vital resource to empower value creation, performance, growth, and success in business ( Zack et al., 2009 ; Richey et al., 2010 ). Hence, strategic value creation can discover and utilized under the umbrella of EL ( Gupta and Sharma, 2004 ). The operational implementation of KMP is to strengthen organizational learning skills. Learned skills use to promote personal experience and human resources at all levels. The certainty about the implementation of KMP diversifies and improves knowledgeable capital ( Ramadan et al., 2017 ). Consequently, a successful business understands that they should directly attend the KMP to develop, create, spread, and continue knowledge ( Masa’deh et al., 2019 ).

Knowledge base view researchers consider firms should substitute practices for successful apprehension, including the collection, evaluation, distribution, and publication of knowledge apprehended inside their operational activities. Firms can adapt and develop innovative processes, tactics, and strategies for connecting with their team members to gather their data for future insights. Nickerson and Zenger (2004) distinguish that a primary task of management is to “sustain above-average profits by continually discovering new knowledge or new solutions that form unique combinations on existing knowledge.” Although some researchers argue that knowledge contributes to the growth of a business’s technical competencies and these activities enable employees to share cross knowledge ( Szulanski, 1996 ).

Under the light of KBV ( Grant, 1996 ), to achieve better performance, effective and efficient deployment of KMP is important as it will lead to the successful utilization of knowledge-based resources ( Mahdavi Mazdeh and Hesamamiri, 2014 ). According to KBV, specific capabilities and performance increase when knowledge is managed effectively ( Leal-Rodríguez et al., 2013 ). KBV agrees that knowledge is generated, stored, and exploited by entities with coordination and integration organizational requirements, not by a single entity ( Miles, 2012 ).

Relationship Between Entrepreneurial Leadership and Entrepreneurial Success

Bass (1985) studied how leadership styles usually impact the level of performance and augmentation in any organization. Entrepreneurs successively execute their businesses with strong leadership commitment, which help them to maintain a successful project for the future. Bhattacharyya (2006) , also argue that “successful business executives are not only good leaders but invariably turn out to be good entrepreneurs as well.” Therefore, a leadership style that generates a suitable comparative environment for entrepreneurship and innovation in the market leads to success.

Some preliminary work was carried out in the 1990s, which drew the attention of numerous researchers to highlight entrepreneurial activities as a driving force for economic growth and development ( Wennekers and Thurik, 1999 ; Peris Bonet et al., 2011 ). Researchers believe that ES is associated with stable economies ( Shakeel et al., 2020 ; Urbano et al., 2020 ). Nonetheless, ES is a complex phenomenon which usually associates with numerous measurements ( Dej et al., 2013 ). Various parameters have their influence on success. Kim and Hann (2019) specified that success is not necessary for every business launched in the market. He also assumed that the assertiveness of entrepreneurs encourages the extension of the business. Hence a business success can be determined over the business momentary performance more specific to generating profits, investments, and productivity.

Entrepreneurship has increasingly been known as the well-admired pathway to performance and market renewal ( Viswanathan et al., 2014 ). This suggests that opportunity is required to develop the relationship between EL and ES. EL can provide a platform to teams in such an environment where they can collect, share, and utilize knowledge effectively and proposed possible solutions ( Renko et al., 2015 ). Many experts now believe that process-oriented culture in business tightly control organizational administration ( Ubaid and Dweiri, 2020 ) enhances performance ( Upadhyay and Kumar, 2020 ), which later leads to success. The above-mentioned features are the key elements of EL that influence ES. Thus, keeping context in mind, the following hypothesis is proposed:

• H1. Entrepreneurial leadership has a positive influence on entrepreneurial success .

Relationship Between Entrepreneurial Leadership and Knowledge Management Processes

Knowledge adoption and skill learning are categorized processes of learning, which hold a significant association with leadership development and behavior ( Vera and Crossan, 2004 ). This underlines that impact of learning directly influences the strategic position of a leader to interact with lower and middle levels of management ( Jyoti and Dev, 2015 ). Hence, without learning it is not possible to achieve goals. In addition, Coulson-Thomas (2004) argue that in the past, training, and development were not considered significant sources of incremental profit, rather than engaging in income generation, the focus was predominantly on cutting costs. However, real-time training, skill development, and mentoring are cost efficient in the long run ( Sullivan, 2000 ). Recently, an increasing number of studies have found that basic education, professional training, skills based training, and professional experience have a significant impact on ES ( Kurczewska et al., 2020 ). Likewise, some researchers contend that education is an extrinsic element that is assumed to be one success factor ( Kolstad and Wiig, 2013 ; Ferreira, 2020 ; Van der Lingen et al., 2020 ).

It is important to provide an educational platform for EVs. When entrepreneurs participate in educational and business incubation their learning and market skills are upgraded ( Shepard, 2013 ). Organizations are prevailed on to formulate various training modules that are contingent upon the requirements of distinct employees ( Abd Rahman et al., 2013 ). The focus is to buoy up the trained employees to implement their skills (knowledge) and develop a knowledge based atmosphere that will improve policies to preserve these employees ( Alagaraja et al., 2015 ). In this regard, the Government of Pakistan provides various training facilities for entrepreneurs ( SMEDA, 2021 ). There are various platforms such as the Small Medium Enterprise Development Authority (SMEDA), National Incubation Centers (NIC), Chamber of Commerce, and other governing bodies that are directly and indirectly associated with entrepreneurs in order to guide Pakistan according to market demand ( Iqbal and Malik, 2019 ).

The positive intentions of leaders toward knowledge flow, inside any organization, significantly encourage their team members to think innovatively ( Rupčić, 2020 ). In contrast, poor communication and lack of knowledge could damage innovation, and does not motivate employees to absorb new information ( Lam et al., 2021 ). A study by Knockaert et al. (2011) identifies the significance of knowledge transfer as a means of enhancing performance in technology based organizations from top level management to team members. Based on the above discussion, we propose the following hypothesis:

• H2. Entrepreneurial leadership has a positive influence on knowledge management processes .

Relationship Between Knowledge Management Processes and Entrepreneurial Success

For any business to achieve success, KMPs are considered important for growth in terms of its intellectual capital ( Hussinki et al., 2017 ). All the aspects of KMP hold a strong influence by the intellectual capital and employee knowledge ( Seleim and Khalil, 2011 ). Most KMPs target to apprehend, acquit, authenticate, and share knowledge. Mehralian et al. (2014) indicate that knowledge acquirement in any venture shows the capability to regulate, establish, and achieve information from peripheral resources and its dynamic toward success. Therefore, the modernization and novelty of existing knowledge reveal the precarious role of KMPs in the improvement of human resources and achieving success.

Venture success and growth is usually associated with entrepreneurs ( Zorn and Taylor, 2004 ). This is also supported by other scholars who recognize that decisions to grow in the market are made by the entrepreneur themselves ( Baumann-Pauly et al., 2016 ), thus for some entrepreneurs most important characteristic is innovativeness ( Drucker, 2014 ). Entrepreneurs cannot only depend on decision making as knowledge and skills are the most important pillars of growth and success ( Kor and Mahoney, 2005 ; Mazzarol and Reboud, 2006 ). Thus, we assumed:

• H3. Knowledge management processes has a positive influence on entrepreneurial success .

The Mediating Role of Knowledge Management Process Between Entrepreneurial Leadership and Entrepreneurial Success

Leaders play a decisive role in the processes of management in information systems. At a certain level, leaders are visionaries, motivators, processors, and provide frameworks that enhance learning capabilities ( Bryant, 2003 ). Some studies have shown the importance of leadership in KMPs. Tanriverdi and Venkatraman (2005) discovered that the proliferation of information sharing is dependent on a firm’s technical capability. Bavik et al. (2018) had a detailed look at the ethical leadership relationship with KMPs and discovered that efficient leadership styles affect the operational process. Hence, EL prefers to improve a person’s knowledge, abilities, and competencies ( Leitch and Volery, 2017 ); they react and transform by augmentation of present knowledge and expertise ( Durst and Runar Edvardsson, 2012 ; Huang et al., 2014 ). With knowledge implementation, a shift in focus has occurred from technological advancements ( Nadolska and Barkema, 2007 ; van der Westhuizen and Goyayi, 2020 ). Strategies are designed to move inputs and products to information and knowledge, altering organizations and considering the basis for competition ( Dhir et al., 2020 ).

Organizations are adapting to a changing external environment, which puts high demands on leaders to provide different skills, knowledge, and practices ( Jansen et al., 2009 ). KMPs are rapidly adopted by organizations to sustain their growth. In most cases, success is associated with KMPs ( Liebowitz, 1999 ; Gray, 2006 ; Paramsothy et al., 2013 ). The performance of any business can be improved by using KM, to sustain its competitive advantage through the accomplishment of targeted work and goals ( Zorn and Taylor, 2004 ; Jaleel et al., 2019 ). Taking advantage of knowledge is critical for any organization. For ES, it is noteworthy to manage knowledge effectively. Hence, the critical role of KM in KS and acquisition play vital role in success ( Headd, 2003 ). For organizational performance, KM aims to create and acquire credible use of knowledge that allow employees easy access to data usage ( do Adro and Leitão, 2020 ). Firms use KM to gather and create potentially useful information and make it accessible to their employees and customers to ensure organizational development and performance ( Aliyu et al., 2015 ).

Employees’ attitudes toward conducting knowledge tasks and participating in the KMPs are forged by transformational leaders who often create a knowledge supporting culture in the form of establishing a collection of values, assumptions, and beliefs relevant to knowledge ( Birasnav et al., 2011 ). Implementation of this culture holds influence on success. Moreover, leadership, according to Wei and Miraglia (2017) , is a KM enabler. According to his study within the organization, KM enables the support of KM performances with opportunities, structural policies, interconnecting the best strategies, endorsing the values of KM, and providing indicators for measuring information effects. Therefore, leadership has a substantial influence on KS among team members. Zhu et al. (2018) discuss the financial and non-financial incentives shared through KS help organizations to develop new products and suggest cost-effective methods. Thus, it is challenging to attain KM success without the dedication of leadership ( Civi, 2000 ). Thus, keeping context in mind, the following hypothesis is proposed:

• H4. Knowledge management processes mediates the relationship between entrepreneurial leadership and entrepreneurial success .

Moderating Role of Knowledge Entrepreneurship

Under the shadow of entrepreneurial opportunities, knowledge base inventions are characterized as scientific and non-scientific ( Drucker, 2014 ). Knowledge fascinates all entrepreneurial sources to gain success and financial benefits. However, to succeed, knowledge base innovation would demand all aspects of knowledge related to innovation, entrepreneurship, and knowledge itself. KE comes from education, skill, and experience ( Donnellon et al., 2014 ). The entrepreneur should understand the balance of available knowledge of all domains rather than only focusing on specific knowledge domains ( Iversen et al., 2009 ). Argyris and Ransbotham (2016) , observed and proposed, a new prototype of project leadership called “Knowledge Entrepreneurship” that incorporates KMP in the domain of managerial skills and technological adaptability. Scholars work on socio-economic institutional complex networks to develop new shapes of latest technology, which effect knowledge entrepreneurs ( Chandler, 1990 ; Garud and Karnøe, 2003 ; Christensen, 2004 ).

Knowledge is one of the most significant predictors of ES. According to Makhbul and Hasun (2011) , sources of knowledge vary from personal experience to private and formal/informal education. He mentioned that a well-informed (educated or aware) entrepreneur can pioneer and elicit innovative ideas, which empower entrepreneurs to grab opportunities evolving from the market.

There is massive potential for KE toward improving performance and attracting customers and stakeholders ( Coulson-Thomas, 2003 ) based on knowledge. KE use the “know-how” for their demand and make their competencies commercial to craft idiosyncratic assistance and arrange for customers with modern incentives ( Coulson-Thomas, 2003 , 2012 ). Based on the above arguments, the following hypothesis was developed:

• H5. Knowledge entrepreneurship moderates the positive relationship between entrepreneurial leadership and knowledge management processes in the way that the relationship will be stronger when there is high knowledge entrepreneurship .

Based on KBV theory and the proposed hypothesis, a conceptual model (see Figure 1 ) has been developed to understand the relationship between variables.

Conceptual model.

Methodology

Sample and data collection.

A quantitative approach was used in this study. The participants were from various cities in Pakistan. Using convenience sampling, data were collected from founders, co-founders, and entrepreneurial leaders of tech-oriented ventures ( Bagheri et al., 2020 ) including IT and software-based companies ( Donate and Sánchez de Pablo, 2015 ). Because KM strategies at IT companies tend to be broader, the management of knowledge is emphasized more in their processes. In addition, technology-intensive industries are based on knowledge that requires a different managerial approach than those in non-knowledge industries. Therefore, in certain situations leadership and HR management play a unique and supportive role in cultivating and implementing KMPs ( Yahya and Goh, 2002 ).

The participant’s collaboration in the research was primarily elicited through telephone. Consequently, after pre-test and alteration, the self-administered structured questionnaire and its cover letter were emailed to each participant. Through email, we also inform each venture owner about the significance of the study and highlight the importance of their feedback by filling out questionnaires. For the follow up at 25 days, a reminder email was sent to non-responding participants. In addition, we also requested co-founders and entrepreneurial leaders to relay the email to other fellow co-founders and entrepreneurial leaders who also belonged to the target population of interest ( Nunan et al., 2020 ).

A total of 430 questionnaires were distributed. Conversely, a total of 390 completed questionnaires were received. The total response rate was 65.69%. Furthermore, the collected data shows the demographic description that male participants were higher in number. The average age of respondents was between 31 and 40 years. The majority of participants had bachelor’s degrees, worked as IT/Software engineers, and had experience of between 1 and 5 years. Related details are mentioned in Table 1 .

Participant demographics description.

Following the recommendations of Armstrong and Overton (1977) , we made certain that non-responding bias was not a major concern and independent samples t -test was executed. We divided respondents into two sets; the first follow-up (early responders) based on participants who initially responded to the questionnaire and the second follow-up (late responders) who answer back after 25 days of reminder. Those who replied after the second follow-up are recorded as comparable to non-respondents ( Armstrong and Overton, 1977 ). Hence, an independent samples t -test was executed to ensure that no significant difference was found among early and late respondent EL, KMP, KE, and ES. In the present study, non-responding bias was not a foremost issue. Additionally, self-reporting scales were exploited in this study, to confirm that common method bias was implemented by Harman’s single factor test ( Podsakoff and Organ, 1986 ). Hence, common method bias was not a serious issue in the present study.

A 5-point Likert scale was used in a questionnaire that mentioned “1” to “strongly disagree” to “5” to “strongly agree.” Items were taken from previous existing studies after understanding the variable of interest.

The study adopted an 8-item scale (Cronbach’s alpha = 0.89) developed by Renko et al. (2015) . The items in this scale reflect the leadership styles and their impact on success. EL construct includes: “ I have creative solutions to problems, and challenges push me to act more innovatively .”

Knowledge Management Process

Based on the four constructs of KMPs (KA, KS, KST, and KAPP); KMP was measured using a 44-item scale developed by Gold et al. (2001) . The KMP comprised of 44-items including 8-items on KA, 10-items on KU, and 10-items on KP (Cronbach’s alpha = 0.85). KS used a 10-items scale (Cronbach’s alpha = 0.94), adopted from Donate and Guadamillas (2010) . KMP items include “ In our organization, the organizational procedures are documented through work procedures, written protocols, handbooks, etc. ,” “ Has processes for acquiring knowledge about new products/services within our industry ,” “ Has processes for converting competitive intelligence into plans of action ,” and “ Can locate and apply knowledge to changing competitive conditions .”

The scale of KE was adopted from McDonald (2002) , 5-items (Cronbach’s alpha = 0.85). KE items included “ We systematically process and analyze information about competitors? ”

Using Fisher et al. (2014) , 9-item (Cronbach’s alpha = 0.71) scale to measure ES based on individual and venture success. The ES measured include: “ exceed the business goals I set out to achieve in founding at least one business and build a business sustainable beyond my involvement .”

Data Analysis and Results

The data harvested from the questionnaire survey were analyzed through the partial least squares structural equation modeling (PLS–SEM) with the path modeling method. The motivation for selecting PLS path modeling was its widespread acceptance in disciplines of management sciences ( Hair et al., 2012 ; Sarstedt et al., 2014a ). Furthermore, the present study aimed to predict the dependent variable (ES) and it is known as the “most fully developed and general system” in SEM studies ( Moustakas, 1994 ). Two-step approaches include the Measurement model and the Structure model was used in the following study.

Measurement Model

The measurement model is also known as the “Outer Model.” It exhibits the relationship between constructs and indictors. It is consist of composite reliability (CR) to calculate internal consistency, individual indicator reliability, and average variance extracted (AVE) to assess convergent validity ( Hair et al., 2012 ; Sarstedt et al., 2014a ). It is used to evaluate the acceptability of the scales used.

In individual item reliability, each item is evaluated based on its outer loadings ( Duarte et al., 2010 ; Sarstedt et al., 2014b ). Researchers consulted a rule of thumb by recommending items whose density is between 0.40 and 0.70 ( Hair et al., 2014 ). However, constructs value lower than 0.6 should be removed ( Gefen and Straub, 2005 ). Hence, the present study was satisfactorily above or equal to the value of 0.6 and more because outer loadings for respective latent variables meet the item reliability criteria (refer to Table 2 ). Consequently, this study meets the reliability criterion successfully.

Factor loading values with Cronbach’s alpha, CR, and AVE.

In CR, researchers proposed an approximated value that should be greater or equal to 0.7 for the consideration of coefficient ( Hair et al., 2014 ). This study demonstrates the CR coefficients for each of the latent variables ranged above 0.75. Therefore, this study signifies the sufficient internal CR of the measures ( Hair et al., 2011 ).

The valuation of convergent validity with AVE has been endorsed by Fornell and Larcker (1981) . Nevertheless, Chin (1998) recommended that for any specific construct the value of AVE should be less than 0.50 and more to designate the convergent validity. The AVE values mentioned in Table 2 directed that the AVE value has been attained at least possible of 0.50; consequently ( Chin, 1998 ), it is determined that the present study established passable convergent validity ( Chin, 1998 ). In addition, Hair et al. (2011) stated same that the estimated value of loading factors in the measurement model should be above 0.6 and AVE values should be above 0.50. Likewise, the CR should be greater than AVE ( Hair et al., 2012 ). Table 2 shows the values of loadings, Cronbach’s alpha, CR, and AVE, which supports the convergent validity of the proposed model.

Discriminant Validity

Discriminant Validity of variable identifies the level up to which constructs correlate and indicators signify only a particular construct ( Hair et al., 2012 ). The present study followed the heterotrait–monotrait (HTMT) ratio procedure for the discriminant validity of the constructs. According to this technique threshold values of the HTMT ratio should equal or 0.90 ( Henseler et al., 2016 ). Thus Table 3 fulfils HTMT ratio procedure.

Discriminant validity following Fornell and Larcker criteria.

The correlations between latent variables and the diagonal are the AVE’s square root mentioned as off-diagonal values in bold numbers.

Structural Model

The structural model is also known as an “inner model.” In the proposed research model, it exhibits the relationships (paths) between the endogenous variable (EL) and exogenous variable (ES). In the structure model, the β-value shows the relationship between the path of dependent and independent variables and the R 2 value predicts the predictive power. Hence, SEM is used to explore the hypothesized model. This study employed a standard bootstrapping technique to attain the significance of path co-efficient, p -values, R 2 value, and t -values. Standardized root means square residual (SRMR) was to measure the fitness of the structural model was measured. According to Hair et al. (2014) and Henseler et al. (2016) a value of a good model should have less than 0.08 SRMR value. In consequence, the value for SRMR was 0.053, which was lower than the threshold value.

The existing study executed a standard bootstrapping technique with 5000 bootstrap samples and 390 cases to identify the importance of the path coefficients succeeding Reinartz et al. (2009) and Hair et al. (2014) . The significance and relevance of the structural model relationships were determined by relating the t -values to the critical t -values for significance levels of 0.05 and 0.010 for every path coefficient.

Hypothesis Testing

Initially, the result revealed that EL has a significant positive influence on ES (β = 0.867, t = 2.712, p = 0.004), Hence, H1 was supported. Similarly, EL also showed a significant positive impact on KMPs with (β = 0.888, t = 6.955, p = 0.000), reveals H2 was supported. Consequently, KMPs reveal a positive relationship on ES (β = 0.797, t = 8.745, p = 0.000) in H3 also supported and identify significant impact. Correspondingly, KMPs as a mediator between EL and ES (β = 0.707, t = 5.713, p = 0.000) is supporting the H4. Moreover, the result shows that KE moderates between EL and KMP relationship (β = 0.791, t = 2.905, p = 0.001). Table 4 shows full estimates of the structural model besides measurements concerned with mediating the variables of KMP and moderating variables of KE.

Finding from SEM (full model).

Tests of hypotheses are one-tail tests, value of p < 0.05; value of t > 1.96; S, supported; NS, not supported.

Mediating Effect

Hypothesis four stated the mediating relation of KMPs in between EL and ES. According to H1, the total effect (H1) of EL has a significant and positive impact on ES (β = 0.867, t = 2.712, p = 0.004) (Mentioned in Table 4 ). However, when KMPs was added as a mediator into the model the total effect reduces and founded not significant (β = 0.160, t = 0.905, p = 1.018). However, the indirect effect of KMPs was founded significant and positive (β = 0.707, t = 5.713, p = 0.000). The result shows that the KMPs have a full mediating effect between EL and ES. Variation accounted for (VAF) calculates the enormousness of the indirect consequence in relation to the entire effect ( Hair et al., 2012 ). Hair et al. (2012) specified that mediation conditions for understanding VAF value should follow; no mediation under 0 > VAF < 0.20, partial mediation under 0.20 > VAF < 0.80, and full mediation over 0.80. In the following study, VAF is 82%, which represents the full mediation. Hence, H4 has been accepted and the results of the mediating effect are shown in Table 5 .

Mediating effect.

Moderating Effect

This study used the product indicator (PI) approach for understanding the moderation effect of KE. The PI approach is a procedure of estimating latent interactions in structural equation modeling According to H5 moderates KE evaluates the positive relationship between EL and KMPs in the way that the relationship will be stronger when there is high KE (β = 0.791, t = 2.905, p = 0.001) and supported H5. F 2 value is used to determine the strength of moderating effect. In this study, the value of F 2 was noted as 0.238 with has medium effect size. Moreover, Figure 2 displays the moderating effect, which shows that KE strengthens the relation between EL and KMPs toward the ES.

Moderating effect of KE.

R 2 , Q 2 , and Effect Size

R 2 value is used to determine the variations in the value of a dependent variable that could be examined by independent variables (one or more than one) ( Fassott et al., 2016 ). The value of R 2 is acceptable according to its demand in the study. Falk and Miller (1992) claim value above 0.10 is acceptable for the R 2 ; however, Chin et al. (2003) mentioned that the value of R 2 is categorized in three ways, 0.60 is a good value, 0.33 is a moderate value, and 0.19 is a weak value. The obtained R 2 of the current study is 0.16 for ES and 0.357 for KMPs, which shows the 16 and 35.7% variance in the dependent variable. This study follows the Falk and Miller (1992) value of the R 2 statement (see Table 6 ).

R 2 and Q 2 values.

The cross-validated redundancy value or Q 2 measures the predictive relevance of the model ( Geisser, 1974 ). It stated that the value of Q 2 is greater than zero so it is considered for predictive relevance. The Q 2 measure size effect has three categories, if greater than 0.000 it is a small effect, if greater the 0.15 it is a medium effect, and if greater than 0.35 it is a large effect ( Hair et al., 2014 ) (Mentioned in Table 6 ).

The study has given an account of the relationship between EL, KMPs, KE, and ES. The recognition of the proposed hypothesis approves the knowledge-based view theory. Firstly, this study revealed a positive influence of EL toward ES, which suggests that the outcomes concur with ( Renko et al., 2015 ; Al Mamun et al., 2018 ), which was also the case for the positive association of EL on performance. This shows that leadership style is characterized by pro-activeness, risk-taking ability, innovative thinking, efficient ways of utilizing proper leadership skills, and higher proclivity for ES. In addition, leaders can utilize their entrepreneurial competencies in a competitive environment to achieve ES ( Ahmad, 2007 ; Mitchelmore and Rowley, 2010 ). This further strengthened our confidence that EL holds a positive significant impact on ES.

Secondly, this study also found a positive significant impact of EL on KMPs. The results endorsed this hypothesis. Leaders are recognized as founders who give foundation to ideologies, vision, and mission ( Kuratko, 2007 ). These foundations help to build consideration of advancement in entrepreneurship. In addition, proper utilization and implementation of knowledge provide support to leadership ( Singh, 2008 ). Therefore, entrepreneurial leaders should provide an open environment for team members to develop solutions, collaborate, and share knowledge ( Renko et al., 2015 ). According to Závodská and Šramová (2018) , knowledge contribution and sharing are one of the key factors toward ES. Likewise, it was advised that effective knowledge management implementation entails proactive EL ( Chaston, 2012 ).

Thirdly, this study identifies the significant impact of KMPs on ES. The findings of this study confirm this hypothesis and also confirms the previous findings of KMPs impact on success ( Cabrera-Suárez et al., 2001 ; Chang et al., 2012 ; Gunasekera and Chong, 2018 ). The KMPs can substantially increase the chances of ES in tech or IT-based organizations ( Chin Wei et al., 2009 ; Knockaert et al., 2011 ). Hence, KBV emphasis has remained crucial in explaining the role of KMPs ( Grant, 2015 ). This proved the validity of a theory positing that organizations can achieve superior results through the effective management of knowledge resources ( Grant, 1996 ).

Fourthly, further analysis shows that the indirect influence of EL on ES through the mediation of KMPs has a significant and positive impact. EL through KMP as a mediator increases the level of success in entrepreneurship ( Chin Wei et al., 2009 ; Alshanty and Emeagwali, 2019 ). This study has confirmed previous research on the mediating role of KMPs ( Huang and Li, 2009 ; Birasnav et al., 2013 ; Donate and Sánchez de Pablo, 2015 ; Sadeghi and Rad, 2018 ). In light of KBV, knowledge is associated with the nature of the job performed by the people in charge and the organizational structure play a pivotal role ( Grant, 1996 ).

Finally, the findings of this study also provide an understanding of the moderating effect of KE which strengthens the relationships between EL and KMPs. Entrepreneurial learning and knowledge give support to businesses for long term survival ( Sullivan, 2000 ). According to Coulson-Thomas (2003) , KE helps to improve performance. This shows that knowledge could facilitate success.

Implications

This present study contributes theoretically to existing literature. It provides evidence that EL holds a strong impact on ES; however, with KMPs and KE it increases the chance of success. Therefore, the following study supports KMPs and KE under the light of KBV theory. Thus, KMPs as mediators and KE as moderators strengthen the relationship between EL to achieve ES. Additional, this study provides new insights, that it is more important for new incumbents (Entrepreneurs) to practice EL skills with KM processes to ensure their safe journey toward ES.

This study has some practical implications for high-tech industry practitioners, small medium enterprises, incubation centers, and researchers in the field of entrepreneurship. Firstly, as stated above this study contributes to literature on EL, KMPs, KE, and ES. Consequently, for better understanding governing and non-governing bodies can derive from this research result. Hence, the graph of not successful ventures could be reduced by introducing KMPs and KE in an EV. Secondly, this study recommended that IT and software owners with knowledge transfer in and out of their organization can develop a strong environment for accomplishing entrepreneurial goals-against entrants.

In managerial implication, mentors, and trainers can help entrepreneurs to polish their leadership skills. In addition, they can mentor entrepreneurs about the operational activities of the venture could be more efficient under KMPs to compete with competitors and aims to achieve ES. Thus, mentors or trainers can highlight the importance of leadership style with accurate knowledge in a specific domain that can help individuals to achieve their desired success. It is noteworthy that success is not only associated with monetary terms it can be non-monetary as well.

Research Limitations and Future Research Directions

Finally, a number of potential shortfalls need to be considered. First, the sample of study only focused on entrepreneurs of Pakistan. We recommend that further studies should undertake in the different demographic locations and can also conduct comparative studies. Second, cross sectional data were used in the present study. Future work should concentrate on longitudinal data and panel data for better understanding. Third, a quantitative survey method was employed. It is proposed that the qualitative method can also be used to understand the in-depth phenomena, and to collect data for future research. Fourth, the target population was founders, co-founders, and leaders from tech-oriented ventures. It is recommended that samples from other industries, including manufacturing or trade related industries, should be utilized in future studies. In addition, our study was only focused on the EL style to recognize its impact and significance on ES; however, paternalistic leadership, dictator leadership, or any other style could be used to evaluate leadership style in a better way. KMPs as a mediator can also replace technology management processes and supply chain processes. Moreover, gender or age could be used to moderate the relationship and help to analyze the significant difference of gender on the impact of EL on ES.

Our work has led us to conclude that in the presence of KMP and KE, EL can enable ES. This paper presented and analyzed an integrated research model that links EL to ES through the mediating role of KMPs and moderating role of KE. This investigation supports literature on leadership and knowledge management by demonstrating that the meaningful use of KMPs can let EL have a noteworthy impact on ES. The result reveals that EL would be more successful when KE is implemented. Thus, venture and ES are somehow related to KMPs and KE. Consequently, leaders, CEOs, and managers should adopt KMPs and KE in their daily routine to practice in their EVs.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by the Professors Committee, Business School, Zhengzhou University, China. As protection of all participants, all subjects read informed consent before participating in this study and voluntarily made their decision to complete surveys. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

NH developed the theoretical model, wrote the manuscript, and did an empirical analysis. BL supervised the whole process and reviewed the manuscript writing. Both authors contributed to the article and approved the submitted version.

Conflict of Interest

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.

Publisher’s Note

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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A Systems View Across Time and Space

• Open access
• Published: 02 June 2023

Entrepreneurial leadership, learning organization and organizational culture relationship: a systematic literature review

• Robson Mekonnin Shiferaw   ORCID: orcid.org/0000-0002-2259-0019 1 ,
• Zerihun Ayenew Birbirsa 1 &
• Shimels Zewdie Werke 1  

Journal of Innovation and Entrepreneurship volume  12 , Article number:  38 ( 2023 ) Cite this article

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6 Citations

Metrics details

The purpose of this study is to examine the relations between organizational culture, learning organizations, and entrepreneurial leadership. The study concentrated on how organizational culture, learning organizations, and entrepreneurial leadership are measured in the literature. The study used a systematic literature review methodology analysis that was published in reputable and peer-reviewed English research journals to look at how organizational culture, learning organizations, and entrepreneurial leadership are related to one another. The study used content analysis on 27 peer-reviewed journal articles that were discovered in various journals examined in the databases, which was based on a systematic examination of the literature. This study offers a comprehensive view of entrepreneurial leadership that has been linked to learning organizations and organizations in various enterprises and nations. The study looked at research approaches, sample sizes, data gathering tools, implications, and limits from the body of literature. The study is also one of the first of its kind to review the research on the connection between entrepreneurial leadership, learning organizations, and organizational culture. The outcomes of this study help the scientific community underline the connection between entrepreneurial leadership, learning organizations, and organizational culture for upcoming policy makers.

Introduction

The relationship between leadership behavioral approach and learning organizational skills and organizational competencies is demonstrated by a relational model, which creates an experimental foundation for the advancement of institutional learning and a further improvement in the future (Tong, 2020 ). Modern businesses should give entrepreneurial leaders, learning cultures, and organizational learning processes serious consideration if they want to maintain their competitive advantage over other business institutions, meet the needs of the community and the market, attract enthusiastic and high-achieving open-minded leaders, and help solve problems (Abbasi & Zamani-Miandashti, 2013 ). Even though they have a wealth of resources, the non-modern cultural institutions have a lot of historical problems, which have somehow prevented them from being inventive and taking more chances. According to some evidence, non-modern organizations have made efforts to participate in new organizational contexts (Chan et al., 2020 ).

Entrepreneurial leaders actively benefit from their institutions and exploit them, and they also influence their supporters by setting an excellent example. They focus supporters’ attention on entrepreneurial goals and inspire them to follow their ambition. Despite the fact that it is focused on the qualities and behaviors of leaders that might support entrepreneurial behaviors, entrepreneurial leadership is distinct from a more general transformational leadership style. However, the two leadership philosophies have certain similarities when it comes to fostering intellectual growth (Renko et al., 2015 ).

According to (Harrison & Roomi, 2011 ), creating standardized skills that aid in balancing innovativeness, risk-taking behavior, and the capacity to utilize scarce resources effectively and efficiently helps integrate, achieveability, and care for specific qualities of entrepreneurial teams. In order to become proficient in taking advantage of opportunities, retaining their teams’ core capabilities for pursuing innovation, and obtaining competitive advantage, learning these broad and specialized concepts concurrently in socially engaging, reflective, and experiential methods is helpful.

The popularity of entrepreneurial leadership, on the other hand, has increased to enhance the performance of innovative leadership since it is a differentiating style of leadership that is necessary for handling difficult problems involving current institutional arrangements. But there was no research on how entrepreneurial leadership techniques of institutional leaders affected innovative mentality (Akmaliah et al., 2014 ). In addition, a thorough definition of entrepreneurial leadership is constructed, which in turn provides the foundation for evidence-based characteristics of its occurrence and its evaluation from a cross-cultural perspective. The creation of theories about how entrepreneurial leadership influences the process of innovation and opportunity hunting is improved by illustrating the scope of entrepreneurial leadership (Bagheri & Harrison, 2020 ).

Compared to other leadership philosophies, entrepreneurial work appears to be more strongly influenced by leadership styles, and opportunities for entrepreneurship endeavors are even more strongly influenced. One significant category of strategic innovator is the entrepreneur. A crucial step for the development of business sectors is for executives in various organizational situations to adopt an entrepreneurial attitude (Felix et al., 2019 ).

Understanding the influence of organizational culture on institutional-level entrepreneurial orientation based on the fundamentals of organizational theory development. Entrepreneurship experts have emphasized the value of entrepreneurial orientation for organizations, but the role that organizational culture plays in fostering the predominance of entrepreneurial orientation has not been thoroughly examined. Critical problems include taking into account how the two primary organizational culture aspects of individuality and collectivism might support entrepreneurial orientations in order to promote and contribute to this new study topic (Lee et al., 2019 ). Therefore, this study examines the relationship between entrepreneurial leadership, learning organization, and organizational culture in different study contexts.

Conceptual model

The concept of entrepreneurial leadership has received increasing interest in recent years. Notwithstanding the growing body of literature from both empirical and conceptual standpoints (Harrison et al., 2018 ). In entrepreneurial teams, while sharing leadership, cofounders share competencies, roles, vision, stress, and decision-making. The study also reveals various individual and team-level factors which facilitate shared leadership and its outcomes (Lyndon & Pandey, 2020 ). The study also explains the mechanism through which a firm’s innovative environment mediates the relationship between entrepreneurial leadership and employees’ innovative work behavior (Li et al., 2020 ). The mediating role of self-leadership in the relationship between participants’ perceptions of entrepreneurial orientation and innovative work behavior (Kör, 2016 ). A complex analysis of the leadership style preferences of university students combined with their managerial and entrepreneurial inclination, and social and cultural resources is rare in the research practice so far (Perpék et al., 2021 ). The time has come for Palestinian higher education institutes to follow the emerging trend of offering formal entrepreneurship courses and programs. It is for sure, it will be an essential step to provide the community with entrepreneurs and self-employers who will create jobs and thus boost the economic situation (Arafeh, 2015 ). The results show that all types of leadership considered in the study have a relevant effect on entrepreneurial activity, particularly on opportunity entrepreneurship (Felix et al., 2019 ). Practicing entrepreneurial behaviors, managers can enhance employees’ affective commitment, creative self-efficacy, and psychological safety (Iqbal et al., 2022 ). The study found that in entrepreneurial teams while sharing leadership, cofounders share competencies, roles, vision, stress, and decision-making. The study also reveals various individual and team-level factors which facilitate shared leadership and its outcomes (Lyndon & Pandey, 2020 ). The critical role that school leaders’ entrepreneurial approaches play in school innovativeness improvement highlights the urgent need for improving school principals’ knowledge and competence in practicing entrepreneurial leadership to bring more innovation (Akmaliah et al., 2014 ).

According to (Wolfe & Dilworth, 2015 ), examining organizational culture context through group relations. In their study, they emphasized the connections between entrepreneurial leadership, learning organizations, and organizational culture in different institutional settings. To study the influence of different entrepreneurial psychological leadership styles on organizational learning ability and organizational performance and to provide a theoretical basis for the improvement of organizational benefits of entrepreneurial enterprises in the future (Tong, 2020 ). The complex and idiosyncratic relationship between culture and entrepreneurial leadership (Tian et al., 2018 ). On the other hand (Alharbi, 2021 ), provides important information to the academic community because there are no further studies on this topic as a reference. According to (Renko et al., 2015 ), entrepreneurial leadership and organizational culture have a relationship in promoting opportunity recognition and exploitation through influencing others. Practitioners apply the combined model of the reflective practitioner and learning organization as this helps innovative leadership (Oeij et al., 2017 ). After critically reviewing relevant literature the following conceptual model (Fig.  1 ) was developed.

Source: Own elaboration, 2022

Conceptual framework.

Conceptual model framework

This study was designed to use a systematic literature review, the researcher selected published peer-reviewed Scopus-indexed journal articles that deal with the relationship between entrepreneurial leadership, learning organizations, and organizational cultures.

This study proposed to answer the following critical questions.

How are the relationship between entrepreneurial leadership, learning organizations, and organizational culture evaluated?

What types of research instruments have been used in those articles to collect data?

In which databases were journal articles of scholars published?

What are the research samples covered by the current literature?

What are some of the entrepreneurial leadership, learning organization, and organizational culture areas that future studies should be focusing on?

Research methods and coding

Study design.

The association between entrepreneurial leadership, learning organizations, and organizational culture was determined by the study through the use of systematic reviews of the literature. With its advantages over narrative and meta-analysis, the researcher favored the systematic review of the literature. Systematic literature reviews differ from narrative reviews in that they present a reliable, trustworthy, scientific, and open procedure to decrease study bias through thorough critical literature searches (De Menezes & Kelliher, 2011 ).

The majority of the publications in this review ( n  = 14) were quantitative, four used the systematic review approach, and only six designed their investigations qualitatively. There were 27 articles total in this review. The remaining three ( n  = 3) used a mixed-methods strategy.

Data collection

A review approach that followed the procedures in the PRISMA framework 2020 for conducting systematic reviews was used to conduct the study review. This makes it possible to coordinate and arrange the data collection process accurately for the remainder of the review process (Fig.  2 ).

Source: Own construction based on McKenzie et al. (2020)

Data Collection Process.

Data collection process

Selection of databases.

The study employed a three-step procedure to identify pertinent scholarly articles. First of all, we selected major business/social sciences databases indexed with SCOPUS (Springer, JSTOR, Tayler, Francis, Emerald insights, Sage). Google Scholar was used to search some published articles that were not included in any mentioned databases above. Further, the research emphasizes the relationship between Entrepreneurial leadership, learning organizations, and Organizational Culture. Thus, the selection of the databases is mainly based on the variables indicated in the topic (Entrepreneurial leadership, Organizational learning, and Organizational culture) through evaluating each article downloaded using different methods of systematic literature review. Hence issues of using SCOPUS or Web of Science for the selection of articles were not as demanding for this study since it is possible to use through inclusion or exclusion criteria.

Inclusion and exclusion criteria

The study was conducted based on inclusion and exclusion criteria. The inclusion criteria consist of search boundary, year of publication, language, and search terms. The search boundary focused on peer-reviewed and reputable journals of Social sciences, leadership, and management, Journal of Entrepreneurship and Organizational culture. Research articles published from 2010 to 2022 were included in the search. The year 2010 was used as a base of the earliest date of interest because, in that year, hoping that many publications made emphasized issues of Entrepreneurial leadership, learning organization, and organizational culture. The search for studies was limited to English-language articles. The study used search engines using the Boolean technique and using search terms on “Entrepreneurial leadership,” Innovative leadership’’, “Entrepreneurial orientation’’, “learning organization,” “organizational learning,” and “organizational culture”.

The exclusion criteria include relevance, quality, and duplication. It was done through critical reading of abstracts and conclusions of downloaded articles from several databases. The relevance was determined by deciding whether articles fit a keyword used as a search string and to ensure the quality, the study excluded unpublished articles, book reviews, Miscellaneous, Books, Working paper series, and Conference papers to enhance the findings from this review. Duplicated articles were excluded by assigning ID codes for each article and manual detection. Finally, the researcher carefully screened articles; after checking and deleting duplicates, we created a publication pool with 400 articles. We screened these articles by using several inclusion/exclusion criteria. A total of 27 articles met the inclusion and exclusion criteria. The review procedure enables the study to create a systematic, trustable, replicable, and transparent method of data collection and analysis of the paper followed during article selection for a systematic review of the literature selection process was organized.

Data analysis

We employed a data analysis strategy that combined descriptive and content analysis in respect to review questions that were established at the beginning of the review phases. Utilizing the data mining form's categories, the descriptive analysis was carried out. To do this, the review matrix was tabulated, especially for the discussion of research features findings utilizing points such databases, kind (conceptual, empirical, or review), and level of analysis. In the section that follows, the reader is given a brief overview of the examined publications in this study thanks to the descriptive analysis that supports the study characteristics sub-section. As a method of data analysis, content analysis was also employed. In the publications, encoding concerns were addressed, and the analysis of the outcomes utilized an interpretive method. We used to analyze the results of the study manually.

Results and discussion

This study adopted a systematic review examining research topics related to entrepreneurial leadership, learning organization, and organizational culture relationship. Besides, the current study targeted to investigate the appropriate methods of organizing data using a review matrix table. To achieve these deliverables of the study, descriptive and content analysis methods were used to reach the conclusion, recommendation, and future research.

Study characteristics

The study characteristics are used to provide insights to the academic community or any other readers with a brief introduction regarding the reviewed articles, the study used points such as databases, type (conceptual, empirical, or review), and level of analysis as study characteristics as follows. Figure  3 shows the pie chart showing the databases used to search articles for systematic review. The result is presented as follows.

Source: Own construction, 2022

Types of a research database.

Types of research databases

As a result, one-third of the research articles examined for this study’s purposes were categorized under the Emerald Insights research database, as shown in Fig.  3 . On the other hand, 14 (or 50%) of those databases’ accesses came from both the Springer and Google Scholar databases. As opposed to this, 7% (or a total of 21%) of the articles assessed came from Sage Online, JSTOR, and Taylor & Francis. This suggests that the Emerald insights research database accounted for 8 (29%) of the research articles that were consulted for the study.

Types of study reviewed

Based on the several study types that were reviewed for this study’s objectives, Fig.  4 explains the study that was reviewed. The graph illustrates how many of the 27 publications employed one of the many research methods grouped above for ease of reference. In those articles, 14 quantitative research approaches (52%) were used in the bulk of the investigations. The majority of the examined publications, however, used a mixed-method approach 3 (11%) and a systematic literature review 4 (15%), while some reviewed articles, 6 (22%), used a qualitative research strategy in their studies. As a result, it can be concluded that the majority of the papers analyzed for this study used quantitative research methods.

Studies reviewed.

Level of analysis for variables

Figure  5 displays a total of 27 publications on entrepreneurial leadership (EL), learning organizations (LO), and organizational culture (OC) that were located in English journal papers in the business, management, leadership, administration, and education domains. Out of the 27 papers analyzed, 12 (or 44%) addressed entrepreneurial leadership, 2 (or 7%) addressed learning organizations, and none addressed organizational culture alone. Additionally, out of the 27 articles reviewed, 2 (7% of them) specifically addressed the relationship between entrepreneurial leadership, learning organizations, and organizational culture, while 6 (22%) of the articles reviewed concentrated on the connection between entrepreneurial leadership and organizational culture.

Types of Variables Reviewed.

In addition, 1 (4%) of the publications evaluated focused on the connection between organizational culture and learning organizations, while 4 (15%) of the articles reviewed discussed entrepreneurial leadership and learning organizations. According to the data, fewer academics have looked into the connection between entrepreneurial leadership, learning organizations, and organizational culture. The analysis only showed how many students combined the three factors of entrepreneurial leadership, learning organizations, and organizational culture in their research. On the other hand, no researcher in the literature chosen for this study addressed the relationship or connection between organizational culture and learning organizations or entrepreneurial leadership. Using several methods for conducting a systematic literature review, we chose articles from among 400 publications that were relevant to the topic. Even for performing a thorough literature study, the majority of scholars only employ one or two publications. In comparison to other systematic literature reviews that have already been done, the 27 papers that were chosen were sufficient for the study.

Types of instrument deployed

Figure  6 shows the various data gathering tools that were employed in the publications under examination. Out of the 27 publications that were reviewed, 11 (41%) used questionnaires, 4 (15%) peer reviews, 4 (15%) interviews, observation 1 (4%), semi-structured interview, online interview 2 (7%), and both questionnaires and interview 3 (11%) interviews. As a result, questionnaires were the primary data collection tools used in the majority of the studies analyzed for this study.

Data collection instruments.

Sample size distribution

The sample size distribution of the reviewed publications across 27 different journal articles is displayed in Fig.  7 . The majority of the 12 scholars’ articles that were reviewed for research articles fall between 15 and 100; 3 journal articles were reviewed between 100 and 200; 2 journal articles were reviewed between 200 and 300; 4 research articles were reviewed between 300 and 400; and 3 research articles were reviewed between 400 and 500. The sample size range employed in the two research studies that were reviewed is between 500 and 600 and 600 and 700. Consequently, references and reviews from studies with various sample sizes were used in this investigation. Accordingly, accuracy and representativeness should rise as sample size does.

Sample size per article reviewed.

Organizing data

Using a review matrix according to (Garrard, n.d.) Guiding procedures. This matrix is used to extract information from the literature and organize it effectively and efficiently. The purpose of the main research question was to find what types of entrepreneurial leadership were associated with learning organization and organizational culture by scholars, and how they were examined through abstracted publication year, authors, methodology/methods, Purpose of the study, instruments, journal titles, main findings, implications and limitations from all 27 articles (See Table 1 ).

Organizing data based on Garrard Review Matrix

Discussions.

Entrepreneurial leadership innovation-oriented organizations have a strong influence on learning organizations and advancement in today’s organizations. Different types of leadership are conducive to building a learning organization. Specifically, understanding how and which entrepreneurial leadership style relates to learning organizations by investigating a structural model of different concepts (Xie, 2020 ). Recently evaluating organizational learning and organizational culture as the foundation for knowledge-driven innovative leadership, Argote and Miron-Spektor ( 2011 ) proposed a novel theoretical framework relating to cognitive and social aspects. There is some literature on the subject of the connection between organizational culture and leadership that is entrepreneurially oriented provided by some academics who have studied both of these topics (Lee et al., 2019 ). Entrepreneurial leadership is frequently hampered by the effect of corporate culture (Engelen et al., 2014 ).

The relationship between entrepreneurial leadership theory, corporate culture, and learning organizational abilities, on the other hand. The development of organizational skills and entrepreneurial attitude are also positively correlated (Altinay et al., 2016 ). Organizational culture and learning structures are both impacted by entrepreneurial leadership, and both have an impact on creativity. The impact of these factors on the innovation potential of educational organizations, as well as the function of leadership in the creation of innovation-friendly environments, are both proven (Gil et al., 2018 ).

Implications for future practices

The study depicted that the current literature deals with the relationship between entrepreneurial leadership, learning organization, and organizational culture. Hopefully, there is an increasing interest and trends for more research on the link between entrepreneurial leadership, learning organization, and organization culture, there is no indication that a more diverse inclusion of different entrepreneurial leadership types and learning organizations concerning organizational culture will be a target of the scientific community. Moreover, the concepts of entrepreneurial leadership, learning organization, and organizational culture link or relationship are less investigated and still demand to be clarified when studying their relationship with one another or other institutional performance in general. Thus, much more research will be required to investigate how entrepreneurial leadership, learning organization, and organizational culture affect institutional performance in different environmental settings. This review of evidence from a total of 27 research articles accessed only three or four research scholars focused on entrepreneurial leadership, learning organization, and organizational culture.

Limitions and future research

This study, like all others, has several limitations that must be taken into account when interpreting the findings. For instance, we only acquired a little amount of insight into a few pieces that had been published for almost 12 years, which may have been one of our limitations. In light of this, we need to think about additional years in the future by interested researchers. The sample size for this study, which was 27 research publications, is likely another drawback. However, this might be rectified by reading more review articles through interested scholars in the future. The succeeding researchers who are invested in their interest in entrepreneurial leadership or innovative leadership techniques in learning organizations and organizational culture have a significant influence on the findings of this review. A leader who supports the overall organizational working environment should establish a learning organization and a dynamic organizational culture, according to the study’s implications.

Additionally, this study suggests that leaders and senior management at a firm level encourage learning organizational practices in relation to organizational goals and vision. A business leader can implement organizational design or rules that support learning and organizational culture. Additionally, systems thinking and the overarching corporate vision should be used while implementing organizational learning and best practices. Future research will specifically examine the following research issues: how does entrepreneurial leadership affect a learning organization, determinants of organizational culture and learning organization towards innovative leadership, factors influencing entrepreneurial leadership through organizational culture.

Availability of data and materials

The authors are ready to share the data at any time.

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Robson Mekonnin Shiferaw, Zerihun Ayenew Birbirsa & Shimels Zewdie Werke

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RMS, ZAB and SZW oversaw the entire process, from literature selection and search to report preparation and policy implications. The authors contributed to all investigational efforts related to the study, as well as report writing and changes based on reviewer comments. Finally, before publication, all authors read comments and made modifications to the final version.

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Shiferaw, R.M., Birbirsa, Z.A. & Werke, S.Z. Entrepreneurial leadership, learning organization and organizational culture relationship: a systematic literature review. J Innov Entrep 12 , 38 (2023). https://doi.org/10.1186/s13731-023-00305-z

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Sustainable leadership and sustainable entrepreneurship: a systematic literature review

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• Volume 5 , article number  188 , ( 2024 )

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• Greice Kely Aragão Ribeiro 1 &
• João Leitão 2  

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

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1 Introduction

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

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

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

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

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

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

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

2 Research method

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

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

2.1 Phase 1—Planning the research

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

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

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

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

2.2 Phase 2—Developing the research

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

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

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

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

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

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

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

3 Results and discussion

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

3.1 Descriptive data analysis

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

Scientific production and average citation per year

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

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

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

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

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

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

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

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

Growth of key-words

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

3.2 Cluster analysis

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

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

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

Map of the most cited documents

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

Map of the documents contributing most

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

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

3.2.1 Cluster 1—Heterogeneity of contexts

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

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

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

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

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

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

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

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

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

3.2.2 Cluster 2—Conceptual analysis

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

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

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

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

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

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

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

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

3.2.3 Cluster 3—Entrepreneur and leader behaviour

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

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

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

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

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

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

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

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

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

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

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

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

3.2.4 Cluster 4—Instruments and motivations

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

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

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

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

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

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

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

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

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

3.2.5 Cluster 5—Coverage of sustainable entrepreneurial leadership

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

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

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

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

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

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

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

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

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

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

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

4 Framework

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

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

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

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

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

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

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

5 Conclusion, implications and limitations

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

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

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

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

a) Sustainable leadership:

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

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

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

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

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

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

b) Sustainable entrepreneurship:

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

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

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

SDG10 Reduce inequality within and among countries.

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

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

SDG12: Ensure sustainable consumption and production patterns.

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

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

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

6 Theoretical and practical implications, and limitations

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

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

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

See Table  11

Data availability

No datasets were generated or analysed during the current study.

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

https://sdgs.un.org/goals

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A servant leadership model can be a game-changer in modern entrepreneurship.

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Chris Kille is the CEO of Payment Pilot and Elevate Outsourcing, operating out of Frisco, TX.

The world of entrepreneurship—a land filled with challenges, victories and late-night caffeine binges. I’ve been on this roller coaster for years, and if there’s one concrete takeaway, it’s this: Leadership models are not one-size-fits-all. Forget the old-school, top-down managerial hierarchies where leaders command and control. Say hello to a transformative approach that flips this ancient script: servant leadership.

I’ve tasted both sides of the apple—the tartness of command-centric regimes and the juicy, nuanced flavors of servant leadership. Trust me when I say, the latter works like a charm. For all the savvy entrepreneurs out there, here’s my deep dive into why a servant leadership model doesn’t just work for me, but could be the game-changer you’ve been seeking, too.

Core Principles Of Servant Leadership: Dissecting The Beast

Before you roll your eyes, this isn’t Leadership 101. We’re diving straight into the nitty-gritty—these are the key characteristics of servant leadership:

• Demonstrate empathy over ego. Unlike traditional leadership models, where the focus is often on the leader, servant leadership pivots toward understanding and empathizing with your team. And let me tell you, empathy isn’t a mere accessory; it’s the backbone.
• Prioritize personal development. People aren’t robots. They have potential that begs to be nurtured. As a servant leader, your primary role is to unlock this untapped reservoir.
• Implement collaborative decision-making. Servant leaders aren’t one-man shows. Decisions are made collectively, integrating insights from the ground up. After all, multiple brains are better than one, am I right?

Implementing The Magic: Actionable Steps For The ‘Aha’ Moments

To adopt this high-level, yet unbelievably actionable, approach, you need to do a few things:

• Switch the spotlight. Instead of making every decision revolve around you or the bottom line, focus on what will benefit your team. More often than not, what’s good for your team will eventually be excellent for your business. Make this your daily mantra!
• Recognize that communication isn’t a one-way street. Welcome to the era where listening skills are as golden as your grandma’s heirloom jewelry. A leader who listens garners respect, trust and—guess what—more dedication from the team.
• Be a catalyst, not a dictator. Inspire and motivate your team to act. Ditch the whip and pick up the baton; lead by example, not by fear.
• Don’t pass the blame. As the leader, the buck stops with you. Period. Own up to your team’s mistakes, learn from them, and devise better strategies for the future.

Case Study: Transforming Startups With Servant Leadership

My startup hit a tough point, and I realized I needed to make some changes. The main problem was people or, more specifically, how they felt and behaved. It wasn’t just about crunching figures or incorporating flashy tech solutions. That’s when I learned about servant leadership. I changed the narrative instead of issuing directives from the top. I started paying close attention to what my team required in order to succeed. We had frank discussions over coffee instead of in the boardroom. I concentrated on assisting people in developing, resolving issues and experiencing value. The outcome? Unbelievable change of heart. The crew was happier, more engaged and totally committed to our shared objective. Productivity soared, team morale skyrocketed and we broke all previous revenue records.

So, I’m not just preaching from a high horse; I’ve lived this transformation. And the changes were nothing short of phenomenal. Why? Because when you have a team that’s actively involved, respected and nurtured, they’ll go above and beyond. You don’t need to micromanage; you’ve unlocked their innate desire to excel.

Future-Proofing Your Enterprise: The Long-Term Gains

Servant leadership is not just a Band-Aid solution for today; it’s the vaccine for future organizational diseases. As we move into an era where human capital is the most invaluable asset, this model ensures that you’re not just ahead of the curve but that you’re drawing the curve. To unlock the benefits:

• Focus on sustainable growth. A team that grows together, stays together. And a cohesive team leads to long-term growth.
• Embrace innovation. A nurtured team isn’t afraid to think outside the box. That’s where groundbreaking ideas come to life.
• Fostering the next line of leadership. Your team members today are your future leaders. A servant leader grooms them for that role. In my experience, it’s an investment with guaranteed dividends.

The Servant Leadership ROI: Measurable Metrics

I know, in the entrepreneurial world, metrics are king. We’re all about measurable results, aren’t we? So, let me satiate your numbers-craving appetite. Implementing the servant leadership model in my business didn’t just result in happier faces at Monday meetings. We saw a staggering 30% increase in overall productivity within six months and our employee retention rate shot through the roof. As for customer satisfaction scores? Let’s just say they’ve never been better. But don’t just take my word for it. There are lots of other real-world examples that showcase how servant leadership enabled companies to outperform their command-and-control counterparts.

Unveiling The Secret Sauce: Emotional Intelligence

“Emotional intelligence” might sound like corporate jargon, but let’s decode this buzzword. It’s the power to perceive, understand and manage emotions—both your own and others’. It’s also the secret sauce behind every successful servant leader. Having a high EQ doesn’t just make you the office hero; it equips you with the ability to handle complex situations, adapt to change and find common ground amid diversity. Emotional intelligence isn’t just a tool; it’s your leadership Swiss Army knife.

Alright, let’s land this plane. I get it; no leadership model is the Holy Grail. But if you’re looking to create a work culture that maximizes both human potential and profits, I dare say that the servant leadership model has got you covered. It worked wonders for me, and it could very well be the paradigm shift your venture needs. So, take the leap and be the servant leader your team deserves.

Forbes Business Council is the foremost growth and networking organization for business owners and leaders. Do I qualify?

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How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

• Charlotte Parbery-Clark 1 ,
• Lorraine McSweeney 2 ,
• Joanne Lally 3 &
• Sarah Sowden 4  

BMC Public Health volume  24 , Article number:  2168 ( 2024 ) Cite this article

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Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n  = 14) with wide representation from local authority ( n  = 8), NHS ( n  = 5) and voluntary, community and social enterprise (VCSE) sector ( n  = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n  = 5), local authority/council ( n  = 8), and voluntary, community and social enterprise (VSCE) ( n  = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n  = 20), local ( n  = 64) or neighbourhood ( n  = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

Post-Doctoral Research Associate, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Joanne Lally

Senior Clinical Lecturer &, Faculty of Medical Sciences, Honorary Consultant in Public Health, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Charlotte Parbery-Clark or Sarah Sowden .

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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• Health inequalities
• Complex whole systems approach
• In-depth qualitative case study

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Journal of Small Business and Enterprise Development

ISSN : 1462-6004

Article publication date: 21 December 2017

Issue publication date: 8 June 2018

The purpose of this paper is to examine entrepreneurial leadership and to determine the entrepreneurial leadership skills which are important for success in a developing economy environment. Specifically, the focus of this research was on entrepreneurial leadership within the retail pharmacy sector in Nigeria.

Design/methodology/approach

This study was guided by an interpretivist-constructionist perspective. By adopting a qualitative approach, the lived experiences of the retail pharmacy entrepreneurs could be understood. In total, 51 semi-structured interviews were the mode of data collection, and data were triangulated via three sources: entrepreneurs, employees, and literature.

From the study results, a vivid picture of entrepreneurial leadership was formed, which in turn provides the basis for an empirical skill-based model of this phenomenon in a developing economy. This study identifies four distinct entrepreneurial leadership skill categories. These include technical/business skills, interpersonal skills, conceptual skills, and entrepreneurial skills. The findings of this study also show the factors and conditions necessary for entrepreneurial leadership in a developing economy.

Originality/value

The findings of this study have implications in theory and practice. Its results provide an empirical, skill-based framework on entrepreneurial leadership in a developing economy, a subject area for which there exists a lack of background literature. In practice, the findings of this study serve as a useful reference for practitioners and policy makers of the skills and other factors required for people to succeed as entrepreneurial leaders.

• Entrepreneurship
• Developing economy
• Entrepreneurial leadership
• African entrepreneurship

Harrison, C. , Burnard, K. and Paul, S. (2018), "Entrepreneurial leadership in a developing economy: a skill-based analysis", Journal of Small Business and Enterprise Development , Vol. 25 No. 3, pp. 521-548. https://doi.org/10.1108/JSBED-05-2017-0160

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ORIGINAL RESEARCH article

Causal associations between severe covid-19 and diseases of seven organs: a proteome-wide mendelian randomization study.

• 1 College of Mathematics and Computer Science, Zhejiang A&F University, Hangzhou, China
• 2 The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
• 3 Songyang County People’s Hospital, Lishui, Zhejiang, China
• 4 MobiDrop (Zhejiang) Co., Ltd., Tongxiang, Zhejiang, China
• 5 Zhejiang Provincial Key Laboratory of Ophthalmology, Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Zhejiang University, Hangzhou, Zhejiang, China

The coronavirus disease 2019 (COVID-19) pandemic poses an enormous threat to public health worldwide. Many retrospective studies and case reports to date have shown associations between severe COVID-19 and diseases of multi-organs. However, the research on the causal mechanisms behind this phenomenon is neither extensive nor comprehensive. We conducted a proteome-wide Mendelian randomization (MR) study using summary statistics from a Genome-Wide Association Studies (GWAS) of severe COVID-19 and diseases related to seven organs: lung, spleen, liver, heart, kidney, testis, and thyroid, based on the European ancestry. The primary analytical method used is the radial inverse variance-weighted (radial IVW) method, supplemented with the inverse variance-weighted (IVW), weighted-median (WM), MR-Egger methods. Our findings have confirmed the association between severe COVID-19 and multiple organ-related diseases, such as Hypothyroidism, strict autoimmune (HTCBSA), Thyroid disorders (TD), and Graves’ disease (GD). And we have also identified certain proteins that are associated with organ-related diseases, such as Superoxide Dismutase 2 (SOD2) and TEK Receptor Tyrosine Kinase (TEK), which are also considered potential drug targets. Phenotype scanning and sensitivity analyses were implemented to consolidate the results for Mendelian randomization. This study provides a compelling foundation for investigating COVID-19 caused diseases in future studies.

Introduction

During the COVID-19 pandemic, the global public health system has faced a significant crisis. Infection with SARS-CoV-2 is associated with symptoms such as chest pain, difficulty breathing, and muscle pain ( Ballering et al., 2022 ). According to a report from the World Health Organization on 9 August 2023, more than 760 million cases and 6.9 million deaths have been recorded globally since December 2019, but the actual numbers may be higher. Despite the effective control of COVID-19 effects post-vaccination, challenges persist ( Hall et al., 2022 ).

Davis et al.'s review details the severe impact of long COVID-19 on organs such as the lungs, heart, pancreas, kidneys, spleen, and liver ( Davis et al., 2023 ). Many patients present with multiple symptoms across multiple organ systems ( Davis et al., 2021 ). Therefore, elucidating the correlation between severe COVID-19 (very severe respiratory confirmed COVID-19) and organ-related diseases holds significant value for public health.

Mendelian randomization (MR) is an analytical method for testing causal relationships between exposures or risk factors and clinically relevant outcomes ( Davey Smith and Ebrahim, 2003 ). The impact of confounding variables and reverse causality on the precision of correlation discovery can be effectively reduced by Mendelian randomization. The number of publicly available Genome-wide association study statistics (GWAS) databases has increased in recent years, and Mendelian randomization is now widely applied in epidemiological research ( Ge et al., 2023 ; Kim et al., 2023 ).

In previous studies, most Mendelian randomization studies on COVID-19 have focused more on causal analysis between single-type diseases ( Li et al., 2022 ; Zhang et al., 2022 ). In this study, we systematically analyzed the association between severe COVID-19 and diseases related to seven organs, aiming to explore the causal relationship between severe COVID-19 and diseases in these seven organs. We used the significant single nucleotide polymorphisms (SNPs) in the severe COVID-19 phenotype as instrumental variables (IVs). However, due to the high false positive rate in MR analysis caused by the presence of numerous instrumental variables, and thanks to the irreplaceable role of proteomics research and the progress made in COVID-19 studies ( Bi et al., 2022 ; Babacic et al., 2023 ), there are now COVID-19-related proteomics datasets available for effectively screening strongly associated instrumental variables. We utilized multi-organ proteomics data from COVID-19 autopsies to screen for corresponding organ diseases before conducting two-sample MR to explore this causal relationship ( Nie et al., 2021 ). Through these analyses, we seek to gain deeper insights into the impact of severe COVID-19 on various organs, providing novel perspectives and treatment strategies for addressing COVID-19-related complications. Additionally, we utilized corresponding databases for drug target exploration and phenotype screening, and constructed Protein-Protein Interaction (PPI) networks.

Materials and methods

In this study, we used a two-sample MR analysis to explore the causal association between exposure and outcome and based on three hypotheses: first, there is a robust correlation between IVs and the exposure factor. Second, IVs are independent of confounding factors that are associated with the outcome. Third, IVs affect the outcome only through the exposure and not through any other mechanisms ( Lawlor, 2016 ). We used the phenotype associated with severe COVID-19 as the exposure. Then, we selected diseases related to seven organs (lung, spleen, liver, heart, kidney, testis, thyroid) as the outcome. The specific workflow of the study is illustrated in Figure 1 . In order to ensure the scientific validity and reliability of the MR analysis, we follow the STROBE-MR guidelines developed by Skrivankova (SAppendix 1) ( Skrivankova et al., 2021 ).

Figure 1 . Description of the study design in this MR study. SNPs, single nucleotide polymorphisms; IVs, instrumental variables.

Data sources

We have used the GWAS summary statistics of severe COVID-19 phenotypes compiled from the COVID-19 Host Genetics Initiative (HGI). ( Initiative et al., 2021 ) ( https://www.covid19hg.org/results/r7/ ), which have been widely utilized in previous studies ( Huang et al., 2022 ; Ge et al., 2023 ). The summary of the information for the corresponding data on severe COVID-19 is presented in Table 1 . GWAS summary statistics of seven organ-related diseases were then filtered from The FinnGen Consortium ( https://www.finngen.fi/en ), and the information for specific diseases is presented in Supplementary Table 1 . The proteomic data used to screen for organ-associated SNPs were obtained from Nie et al.’ study ( Nie et al., 2021 ). In this study, using tandem mass tagging (TMT)-based shotgun proteomics, they quantified 11,394 proteins and found that 5,336 of them were significantly dysregulated in at least one organ in COVID-19 patients (Lung:1606; Spleen:1726; Liver: 1969; Heart: 919; Kidney: 2227; Testis: 10; Thyroid: 1297) ( Nie et al., 2021 ). In our study, we directly downloaded the list of differential proteins provided by this research for subsequent analysis.

Table 1 . Description of the data involved in Mendelian randomization studies.

IV selections

We selected appropriate IVs for MR analysis from two different GWAS summary statistics through a rigorous series of screens to meet the three fundamental assumptions. Initially, a genome-wide significance threshold ( p < 5 × 10 −5 ) to select SNPs that are stably associated with severe COVID-19, and the reasonableness of this threshold setting has been confirmed in previous studies ( Ge et al., 2023 ).

The characteristic of Linkage Disequilibrium (LD) is the non-random correlation between two or more genetic loci with advantageous hereditary traits. r 2 > 0.001, kb > 10000 was set to screen the appropriate SNPs, thus reducing the impact of chain-imbalanced LD on the results. The threshold used in this study was determined by analyzing a large dataset including European genomes. Previous multiorgan proteomics data on COVID-19 autopsies were used to screen for SNPs for corresponding organ diseases that correlate with COVID-19 ( Nie et al., 2021 ). To ensure a strong association between exposure and outcome, we estimated the F-statistics to assess the strength of IVs, which is calculated by dividing the square of beta by the square of the standard error (SE). Strong IVs with F-statistics greater than 10 were used ( Burgess et al., 2011 ). Furthermore, we conducted phenotype screening of IVs to confirm the exclusion of confounding factors affecting the results.

Statistical analysis

In this MR study, we used radial inverse variance-weighted (radial IVW) and inverse variance-weighted (IVW) as the primary analysis method. The Radial MR method removes the corresponding outliers and reduces the effect of pleiotropy on the results ( Bowden et al., 2018 ). IVW assumes that all genetic variants can be used as valid instrumental variables. it is very stable in detecting causality and can provide impact estimates with significantly lower variance. The p -value of radial IVW less than 0.05 was then used as a screening criterion to screen out relevant diseases for the next analysis. Building upon the second-order weighted radial framework, the study also supplemented two additional methods, MR-Egger regression and weighted median (WM). The MR-Egger method was able to analyze the possible genetic pleiotropy of the IVs involved in the study ( Bowden et al., 2015 ). In MR-Egger regression, if the intercept term is zero or lacks statistical significance, the regression slope can be interpreted as the estimated causal effect of exposure on the outcome. The weighted median (WM) method can provide consistent causal estimates in the presence of numerical errors for half of the IVs ( Bowden et al., 2016 ). According to the standard of previous studies ( Freuer and Meisinger, 2023 ; Wang et al., 2023 ), it is generally believed that in a study, the radial IVW result less than 0.05 indicates statistical significance and suggests the presence of a corresponding causal relationship.

Then we evaluate the heterogeneity of IVs based on the second-order weighted radial using I 2 statistics and Cochran’s Q test. When the I 2 statistic fell between 0% and 25%, it indicated only mild heterogeneity. When the value falls within the range of 25%–50%, it indicates moderate heterogeneity, and an I 2 statistic above 50% indicates the presence of significant heterogeneity. If the p -value of Cochran’s Q test is less than 0.05, it indicates the presence of heterogeneity. Conversely, if the p -value is equal to or greater than 0.05, it indicates the absence of heterogeneity. Additionally, the pleiotropy test and Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) test are employed to assess horizontal pleiotropy. If the p -value of the pleiotropy test is less than 0.05, it indicates the presence of pleiotropy; if the p -value is greater than 0.05, it suggests no pleiotropy. In the MR-PRESSO test ( Verbanck et al., 2018 ), a global test p -value less than 0.05 indicates the presence of pleiotropy, while a p -value greater than 0.05 suggests no pleiotropy. All these analyses were conducted using the “TwoSampleMR”, “RadialMR”, “MendelianRandomization”, and “MR-PRESSO” packages in R (version 4.2.2).

Druggable proteins identification, phenotype scanning and PPI network

We mapped the SNPs obtained from the MR analysis to their corresponding proteins, and assessed the druggability of these proteins. We searched these proteins in the DrugBank database. For the proteins identified in the drug database, we documented information regarding the drug names and the associated diseases.

We also conducted phenotype scanning, searching previous GWAS to reveal the associations of identified proteins with other traits. Phenotype scanning was performed using the LDtrait Tools ( https://ldlink.nih.gov/ ). SNPs were considered pleiotropic under the following criteria ( Ballering et al., 2022 ): significant associations at the genome-wide level ( p < 5 × 10 −5 ) ( Hall et al., 2022 ); GWAS conducted in European ancestral populations ( Davis et al., 2023 ); SNPs associated with known risk factors, including metabolic traits, proteins, or clinical characteristics.

To further evaluate the protein networks of individual organ proteins associated with COVID-19, we constructed protein interaction networks using the STRING (Search Tool for the Retrieval of Interaction Gene/Proteins) database ( https://cn.string-db.org/cgi/input.pl ).

The results of the MR analysis for all diseases are presented in Figure 2 and Supplementary Table 1 , showing both IVW and radial IVW results. We selected 13 diseases with positive radial MR results and conducted a literature search on PubMed. This confirmed that there is clinical evidence for nine of these diseases—namely, pneumonia, Streptococcus pneumoniae (SP), liver disease, kidney cyst (KC), other specified disorders of the kidney and ureter, other disorders of the kidney and ureter, thyroid disorders (TD), Graves’ disease (GD), and hypothyroidism (HTCBSA). Detailed information on these diseases can be found in Table 1 . All SNPs used for the analysis are listed in Supplementary Table 2 .

Figure 2 . Association of severe COVID-19 in MR analysis with organ-related diseases. Higher bars represent lower p -values and stronger causal associations.

The casual effect of severe COVID-19 on lung-related diseases

According to Figure 3 , the radial IVW analysis indicates a causal association between severe COVID-19 and pneumoniae (OR and 95% CI: 0.938, 0.88 to 1.00; p = 0.041). Due to the absence of outliers identified through second-order weighted radial regression, the results of the original IVW and radial IVW remain consistent. The results from MR-Egger (OR and 95% CI: 1.017, 0.88 to 1.17; p = 0.831) and WM (OR and 95% CI: 0.949, 0.88 to 1.03; p = 0.206) did not show significant associations. According to the Cochran’s Q test results (I 2 = 0.0%, p = 0.754) in Table 2 , there was no heterogeneity observed among severe COVID-19 and pneumoniae. In addition, the pleiotropy test ( p = 0.270) and MR-PRESSO results ( p = 0.791) indicate no horizontal pleiotropy between severe COVID-19 and pneumonia.

Figure 3 . Forest plots of causal effects of severe COVID-19 in organ-related disease. CI, confidence interval; OR: odds ratio; SNPs, single nucleotide polymorphisms.

Table 2 . Heterogeneity and pleiotropy tests of the Mendelian randomization studies.

In Figure 3 , the IVW results for severe COVID-19 and SP were consistent with the radial IVW results, both of which were significant (OR and 95% CI: 0.626, 0.42 to 0.93; p = 0.021). MR-Egger (OR and 95% CI: 1.388, 0.55 to 3.27; p = 0.547) and WM (OR and 95% CI: 0.694, 0.41 to 1.18; p = 0.178) analyses do not yield significant results. The results of Cochran’s Q test (I 2 = 4.2%, p = 0.381) in Table 2 indicate no heterogeneity between various COVID-19 phenotypes and SP. Pleiotropy test ( p = 0.115) and MR-PRESSO results ( p = 0.428) also fail to demonstrate pleiotropy between the two.

The casual effect of severe COVID-19 on liver-related diseases

According to the radial IVW results in Figure 1A , there was a causal association between severe COVID-19 and liver diseases (OR and 95% CI: 0.906,0.82 to 0.99; p = 0.038). A correlation was also not presented in the other models. According to the results of Cochran’s Q test (I 2 = 0.0%, p = 0.707) in Table 2 , no heterogeneity was found between the results of COVID-19 and liver diseases, and the results of the pleiotropy test ( p = 0.769) and MR-PRESSO ( p = 0.715) similarly showed no pleiotropy.

The casual effect of severe COVID-19 on kidney-related diseases

According to Figure 3 , after employing radial MR to remove horizontal pleiotropy from IVs, the VW analysis of severe COVID-19 and KCI shows an association (OR and 95% CI: 1.248,1.00 to 1.55; p = 0.048), and the global IVW results did not show a correlation (OR and 95% CI: 1.139,0.90 to 1.44; p = 0.280). No significant associations were found in the other models. According to Table2 , Cochran’s Q test ( p = 0.724), pleiotropy test ( p = 0.903) and MR-PRESSO ( p = 0.762) also showed no interference from heterogeneity and horizontal pleiotropy.

In both types of other disorders of kidney and ureter, the overall IVW did not show a significant association, but after removing outliers, the radial IVW analyses for both exhibited significant results ( Figure 3 ). Furthermore, results from Cochran’s Q test, pleiotropy test, and MR-PRESSO all indicate the absence of heterogeneity and horizontal pleiotropy interference ( Table 2 ).

The casual effect of severe COVID-19 on thyroid-related diseases

In the IVW analyses, a corresponding causal relationship between severe COVID-19 and TD is found (OR and 95%CI: 0.919, 0.85 to 1.00; p = 0.046) ( Figure 3 ). After conducting second-order weighted radial regression, it was found that the presence of two outliers could cause horizontal pleiotropy in the MR analysis. Despite the removal of horizontal pleiotropy, the radial IVW results remain significant (OR and 95%CI: 0.926, 0.87 to 0.98; p = 0.008) ( Figure 3 ). The Cochran’s Q test results indicate no heterogeneity between severe COVID-19 and TD. Furthermore, both pleiotropy test and MR-PRESSO results suggest that the use of radial MR, after removing outliers, has mitigated the interference of horizontal pleiotropy ( Table 2 ).

The results of Severe COVID-19 and HTCBSA did not present a correlation under the IVW model (OR and 95%CI: 0.895, 0.80 to 1.01; p = 0.062). Following the exclusion of three outliers’ impact on horizontal pleiotropy, the results under the radial IVW model showed significance (OR and 95%CI: 0.897, 0.83 to 0.96; p = 0.003) ( Figure 3 ). Moreover, Cochran’s Q test results (I 2 = 0.0%, p = 0.843) indicated the absence of heterogeneity afterward, and pleiotropy test ( p = 0.551) and MR-PRESSO ( p = 0.848) results also demonstrated the complete removal of horizontal pleiotropy ( Table 2 ).

The IVW analysis of severe COVID-19 and GD risk as shown in Figure 3 also did not show an identifiable causal relationship (OR and 95%CI: 0.823, 0.66 to 1.02; p = 0.080). After removing the influence of a single outlier on the outcomes, the radial IVW results suggest the existence of a correlated causal relationship (OR and 95%CI: 0.757, 0.65 to 0.94; p = 0.011). The results of MR-Egger and WM did not present a recognizable causal relationship. Results from Cochran’s Q test (I 2 = 0.0%, p = 0.803), pleiotropy test ( p = 0.392), and MR-PRESSO ( p = 0.793) also indicate no interference from heterogeneity and horizontal pleiotropy ( Table 2 ).

Druggability of identified proteins, phenotype scanning and PPI network

Among them, Superoxide Dismutase 2 (SOD2, P04179) and TEK Receptor Tyrosine Kinase (TEK, Q02763) have been confirmed as drug targets for COVID-19 ( Supplementary Table 3 ). Desmoplakin (DSP, P15924) is a relevant drug target for the treatment of pneumonia, while SOD2 is used in the treatment of Hepatitis B. Currently, no drug targets have been found for the treatment of kidney and thyroid-related diseases. Information on drug targets and their associated drugs and diseases can be found in Supplementary Table 3 .

Through phenotype scanning, we did not find any pleiotropic SNPs that could interfere with the experimental results. DSP is associated with idiopathic pulmonary fibrosis, lung dysfunction, chronic obstructive pulmonary disease, interstitial lung disease, and advanced glycation end product receptor levels. Phospholipid Scramblase 1 (PLSCR1, O15162) is associated with COVID-19. Lamin A/C (LMNA, P02545) is correlated with white blood cell count, and Nephronectin (NPNT, Q6UXI9) has been identified as a major gene influencing lung function, respiratory system diseases, chronic obstructive pulmonary disease, and peak expiratory flow rate.

After uploading all the genes used as instrumental variables in MR analysis to the STRING online database, we obtained a PPI network with color modification ( Supplementary Figure 1 ).

As shown in previous studies, long and severe COVID-19 affect multiple organ systems ( Davis et al., 2023 ). We further verified the association between severe COVID-19 and some organ-related diseases, such as Hypothyroidism, strict autoimmune (HTCBSA), Thyroid disorders (TD), and Graves’ disease (GD). This study builds upon the research of Nie et al. ( Nie et al., 2021 ), further exploring the existing associations between COVID-19 and potential organ diseases, providing valid support for previous clinical results and retrospective studies.

Our study demonstrated an observable causal relationship between severe COVID-19 and pneumonia, as well as between severe COVID-19 and streptococcus pneumoniae (SP) ( p = 0.021 and p = 0.041). The damage of COVID-19 to lung has long been confirmed by numerous studies ( Berlin et al., 2020 ; Blanco et al., 2021 ; Su et al., 2021 ). Pneumonia is one of the main clinical manifestations of severe forms of COVID-19 ( Li et al., 2020 ). The study by Angela et al. also confirmed the existence of an effect of COVID-19 on SP ( Brueggemann et al., 2021 ) O'Toole’s study revealed the multifaceted impact of COVID-19 on bacterial infections, with the presence of infectious bacteria in patients admitted to the hospital with severe COVID-19 ( O’Toole, 2021 ). It is worth noting that our study did not observe a potential causal relationship between idiopathic pulmonary fibrosis or interstitial lung disease and COVID-19 ( p = 0.329 and p = 0.436). However, Wendisch et al.'s study established a correlation between COVID-19 and idiopathic pulmonary fibrosis ( Wendisch et al., 2021 ). Additionally, several previous studies have confirmed that COVID-19 can lead to interstitial lung disease ( Myall et al., 2021 ; Barash and Ramalingam, 2023 ).

In our MR analysis, we observed a causal relationship between severe COVID-19 and liver disease ( p = 0.0384). In the review by Dufour et al., they are pointed out that liver injury may be caused by multiple factors, including the direct cytopathic effects of viruses, exaggerated systemic immune responses, vascular damage, coagulation disorders, and drug use ( Dufour et al., 2022 ). In our study, although no significant causal association between severe COVID-19 and chronic hepatitis was found ( p = 0.053), Dufour et al. noted that the risk of adverse outcomes after SARS-CoV-2 infection was increased in patients with chronic liver disease and cirrhosis ( Dufour et al., 2022 ). Based on this finding, we reasonably speculate that there may be a clinical association between severe COVID-19 and chronic hepatitis. It is important to note that MR analysis relies on statistical models and data analysis, which may not fully capture the complexities of the real world. Due to the possibility of false negatives in genetic marker screening and validation during the MR analysis process, some causal relationships may not have been fully captured. According to Portincasa et al.‘s study, patients with COVID-19 are usually associated with metabolic disease, and in the presence of metabolic abnormalities, COVID-19 may exacerbate nonalcoholic fatty liver disease through the interaction of inflammatory pathways and direct or indirect effects of the virus on the liver ( Portincasa et al., 2020 ). Our study still fails to reflect this point ( p = 0.841).

In studies of severe COVID-19 and kidney-related diseases, COVID-19 is thought to trigger chronic kidney diseases and acute kidney injury ( Pecly et al., 2021 ; Long et al., 2022 ). in our study, although an association between severe COVID-19 and chronic kidney diseases was not found, the presence of a false negative ( p = 0.083) could not be ruled out. In addition, we also found an association between severe COVID-19 and kidney cyst ( p = 0.048), although we did not find direct evidence of an association, as chronic kidney diseases may trigger kidney cyst. In the study by Chan et al., it was found that out of 3993 COVID-19 hospitalized patients, 1835 (46%) patients developed acute kidney injury ( Chan et al., 2021 ). However, in this MR analysis, none of the individual acute kidney diseases demonstrated an association with COVID-19. ( Supplementary Table 1 ).

The thyroid disorders caused by COVID-19 has been widely demonstrated ( Khoo et al., 2021 ; Lui et al., 2024 ). HTCBSA is one of the major subtypes of hypothyroidism. Some previous studies have provided evidence of COVID-19-related hypothyroidism ( Muller et al., 2020 ; van Gerwen et al., 2020 ; Burekovic et al., 2022 ). In our study, a causal association between severe COVID-19 and HTCBSA was observed, but results for some other rare subtypes of hypothyroidism were negative. In a previous MR analysis, COVID-19 was confirmed to be a risk factor for hypothyroidism and there was no evidence to support an association between COVID-19 and hyperthyroidism ( Zhang et al., 2022 ). This is consistent with the results we obtained. It is important to note that while our study did not find direct evidence linking severe COVID-19 with hyperthyroidism, we did observe a correlation between severe COVID-19 and GD ( p = 0.011). COVID-19 has been recognized as a potential trigger for GD, and there have been several case reports and studies of patients who developed symptoms of GD after infection with COVID-19 ( Harris and Al, 2021 ; Tutal et al., 2022 ). For such results above, we believe that although GD is a common cause of hyperthyroidism, there are still other causes that induce hyperthyroidism, and severe COVID-19 and hyperthyroidism may not be directly linked.

In our MR analysis of severe COVID-19 and heart-related diseases, only one condition (cardiovascular disorders originating in the perinatal period, p = 0.024) showed a correlation. However, there is a lack of corresponding clinical studies to validate the potential causal relationship with COVID-19. Although some studies suggest that COVID-19 infection may increase the risk of myocarditis and pericarditis ( Lindner et al., 2020 ; Patone et al., 2021 ), our research did not find a direct causal relationship between the two.

In our research, we only identified one spleen-related disease associated with COVID-19 (spleen cyst, p = 0.047). Despite studies by Jana et al. indicating that severe COVID-19 pneumonia can lead to loss of B cells in the bone marrow or spleen ( Ihlow et al., 2021 ), there is no direct evidence to establish a direct or indirect association between COVID-19 and spleen cyst.

A large number of previous studies have shown that COVID-19 affects the human reproductive system ( La Marca et al., 2020 ; Seymen, 2020 ). In fatal cases of COVID-19 infection, viral infection associates with activation of interferon pathways and downregulation of testis-specific genes involved in spermatogenesis ( Basolo et al., 2023 ). However, due to the design of our methods, after multiple layers of screening, we were unable to find IVs that could be used in this study to infer the potential association that exists between sever COVID-19 and testis. This limitation highlights the challenges we face in studying the effects of COVID-19 on the male reproductive system and suggests directions for future research, such as improving data collection and research methods to better understand the specific mechanisms by which the virus affects the testis.

Limitations

While this MR study offers a comprehensive and effective causal analysis for COVID-19 and various organ-related diseases, there are still some limitations. First, COVID-19 presents with a wide range of clinical manifestations and comorbidities, and some of these potential factors may predispose to the development of related diseases. In this study, although we used proteomic data related to COVID-19 for screening to minimize confounding, we could not guarantee that all potential factors were excluded. Second, in this study, we only used Genome-Wide Association Studies (GWAS) summary data from European populations due to the lack of data from other populations, and therefore we cannot guarantee that our conclusions will hold true in other populations. Finally, although we ruled out weak IVs, pleiotropy, and LD through our experimental design, the IVs we used usually failed to account for most of the variance, which may result in MR analyses that do not have a high degree of statistical validity and are at risk of false-negative or false-positive results.

Our research has confirmed the association between severe COVID-19 and multiple organ-related diseases. However, with some proven organ-related diseases, such as chronic hepatitis, chronic kidney disease and hyperthyroidism, we did not find a causal link. In addition, we have identified some proteins associated with organ-related diseases and corresponding drug targets. We hope that future MR studies can utilize larger and more precise GWAS data to refine our findings.

Data availability statement

Publicly available datasets were analyzed in this study. This data can be found here: The COVID-19 Host Genetics Initiative (HGI) data repository ( https://www.covid19hg.org/results/r7/ ) and the FinnGen database ( https://www.finngen.fi/en ).

Author contributions

YS: Data curation, Investigation, Methodology, Resources, Visualization, Writing–original draft, Writing–review and editing. YZ: Funding acquisition, Investigation, Supervision, Writing–review and editing. Y-yX: Investigation, Supervision, Writing–review and editing. XL: Investigation, Writing–review and editing. JW: Investigation, Writing–review and editing. HP: Funding acquisition, Supervision, Writing–review and editing. LW: Investigation, Project administration, Supervision, Writing–review and editing. TZ: Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Writing–review and editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. The study was funded by 2023 Faculty-level Supporting Disciplines - Ophthalmology (Zhejiang Provincial Hospital of Chinese Medicine Discipline High-quality Development Boosting Program) (2D02320), Leading Innovative and Entrepreneur Team of Zhejiang Province (2022R02005), the grant from startup found of Zhejiang A&F University under Grant (203402007101). The funders had no role in the study design, data collection, data analysis, interpretation, or writing of the report.

Acknowledgments

The authors thank all scientists and individuals involved in the COVID-19 Host Genetics Initiative and FinnGen Consortium for their kind contribution to data. During the preparation of this work the author(s) used ChatGPT3.5 in order to polish the language of the initial draft for better readability.

Conflict of interest

Author HP was employed by MobiDrop (Zhejiang) Co., Ltd.

The remaining 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.

Publisher’s note

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.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fgene.2024.1421824/full#supplementary-material

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Keywords: severe COVID-19, causal effect, mendelian randomization (MR), organ-related diseases, proteome

Citation: Shen Y, Zhang Y, Xu Y-y, Li X, Wu J, Pei H, Wang L and Zhu T (2024) Causal associations between severe COVID-19 and diseases of seven organs: a proteome-wide mendelian randomization study. Front. Genet. 15:1421824. doi: 10.3389/fgene.2024.1421824

Received: 23 April 2024; Accepted: 29 July 2024; Published: 13 August 2024.

Reviewed by:

Copyright © 2024 Shen, Zhang, Xu, Li, Wu, Pei, Wang and Zhu. 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: Tiansheng Zhu, [email protected] ; Linyan Wang, [email protected]

† These authors have contributed equally to this work and share first authorship

‡ These authors share last authorship

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.